1=10  Uo  N75 


Effprfttrp  Htbrarg 


■^    ^ 

.^A.  ^i'./»^^ 


^n^. 


DISEASES    OF 

MMm  ni  Mn\m 

A    SERIES    OF    MONOGRAPHS 

By  Prof.  DR.  CARL  von  NOORDEN 

Physician-iU'Ckie/  io  the  City  Hospital,  Frankfort- 
071-Main 

Authorized  American  Edition 
Edited  by  Boardman  Reed,  M.D.,  Philadelphia 


It  is  due  to  the  disorders  of  metabolism  and  nu- 
trition that  degeneratire  changes  cut  short  the 
activities  of  so  many  men  and  women  in  middle 
life, — that,  in  these  latter  days,  senility  and  death 
itself  come  prematurely  to  a  very  large  proportion 
of  mankind, 

I.— Obesity,  the  Indications  for  Reduction  Cures, 

founded  upon  a  critical  scientific  study,  by  this 
eminent  pathologist  and  clinician.  Small  8vo., 
60  pages,  cloth,  ...  -       50c. 

11.— Nephritis.— The  author's  treatment  of  the  va- 
rious forms  of  Bright's  Disease  is  based  on  ex- 
haustive experiments  and  bed-side  observations. 
Small  8vo.,  112  pages,  cloth,  -  -    $1.00. 

III.— Colitis.- This  is  a  masterly  treatment  of  the 
complex  subject  of  Membranous  Catarrh  of  the 
Intestines  (Ci^/zVix  J/z^ror^).  Small  8vo.,  64  pae:es, 
cloth,    -.-...       50c. 

IV. — The  Acid  Autointoxications.— Small  Svo., 
So  pages,  cloth,  ....        5(>c. 

Sent  prepaid  en  receipt  of  price. 

Other  Important  Volumes  in  Preparation. 

E.  B.  TREAT  &  CO.,  Pub.,  New  York 


CLIXICALTREATISES 

on  the 

PATHOLOGY  -  -  ^  THERAPY 

of  DISORDERS  of 
METABOLISM-'^XUTRITIOX 

By 

Prof.  DR.  CARL  von  NOORDEN 
Pl^fstdan  in  Chief  to  the  City  Hospital^  Frankfort  a.  M. 


Authorized     American     Edition 

TS-^NSLATED  UNDER  the  DIRECTION  of 

B  o  A  R  D  M  A  N  Reed,  M.  D  .  , 
Professor  of  Diseases  of  t  he 
Gastro-Intestinal  Tract, 
Hygiene  and  Climatology, 
Department  of  Medicine,  Templk 
College;  Physicl\n  to  the  Samari- 
tan Hospital,  Philadelphia,  etc. 


PART   I 

OBESITY 

THE  INDICATIONS  FOR  REDUCTION  CURES 


NEW  YORK 

E.  B.  TREAT  &  COMPANY 
1904 


Copyright,  1903, 
by 
B.  B.  TREAT  &  COMPANY 
Ail  rights  reserved. 


A/ 73 
pi- 1 


PREFACE  TO  THE  AMERICAN  EDITION. 

For  many  years  I  have  been  occupied,  with  my 
assistants  and  pupils,  in  an  exhaustive  study  of  the 
disorders  of  metabolism  and  nutrition.  The  result 
of  this  work  has  been  a  number  of  short  essays  pub- 
lished in  various  periodicals,  and  several  longer  mono- 
graphs (Textbook  on  the  Pathology  of  Metabolism, 
Berlin,  1893;  Diabetes  and  Its  Treatment,  Berlin,  ist 
edition,  1893;  3^^  edition,  1901 ;  Chlorosis  in  Noth- 
nagel's  Handbook  of  Pathology  and  Therapy,  Vienna, 
1887;  Obesity,  in  the  same  Handbook,  Vienna,  1900.) 
The  wishes  of  my  friends  and  pupils  have  induced  me 
to  establish  a  medium  for  the  publication  in  collected 
form  of  the  results  of  our  increasing  experience  in 
the  pathology  and  therapy  of  the  disorders  of  metab- 
olism and  nutrition.  The  first  volume  in  this  col- 
lection (On  the  Indications  for  Reduction  Cures), 
and  the  second  (On  the  Treatment  of  Acute  Nephri- 
tis and  Chronic  Atrophic  Kidney),  have  been  already 
issued  in  German,  the  publisher  being  A.  Hirsch- 
wald,  Berlin.  The  other  numbers  should  appear  at 
intervals  of  four  to  six  months.  It  has  been  arranged 
to  have  the  collection  contain  not  only  dissertations 
from  my  pen,  but  also  writings  by  my  assistants  and 
pupils, — of  course  under  my  control  and  responsibility. 
The  monographs  are  to  express,  above  all,  the  personal 
views  and  observations  of  the  writers;  or  they  will 


^  PREFACE. 

contain  collective  presentations  upon  important  ques- 
tions. Only  such  subjects  will  be  chosen  as  are  of 
importance  and  interest  to  every  physician. 

The  following  themes  are  under  consideration  for 
the  immediate  future  but  not  positively  decided  upon : 

The  Treatment  of  Colica  Mucosa  (Enteritis 
Pseudomembranacea) . 

The  Medicinal  Treatment  of  Diabetes  Melli- 

TUS. 

Indications  for  and  the  Methods  of  Carrying 
OUT  Feeding  (mast)  Cures. 

The  Technique  of  Reduction  Cures. 

The  Significance  of  Aceton  in  Diabetes  Mel- 

LITUS. 

It  is  a  source  of  satisfaction  to  me  to  announce 
that  Messrs.  E.  B.  Treat  &  Co.,  New  York,  have 
undertaken  to  publish  the  collection  of  these  mono- 
graphs in  English.  Particular  care  will  be  taken  to 
have  them  appear  hereafter  as  nearly  simultaneously 
in  New  York  and  in  Berlin  as  possible;  and  I  hope 
that  this  American  Edition  will  meet  with  the  same 
approbation  which  I  am  happy  to  say  has  been  ac- 
corded the  German. 

Prof.  Dr.  Carl  von  Noorden, 


CONTENTS. 

Introductory  .         .         .         .  .  ii 

I.  Simple  Obesity  in  otherwise  Healthy 

Subjects 19 

a.  Advanced  Degrees  of  Obesity      .         .  19 

h.  Medium  Degrees  of  Obesity  .         .  20 

c.  Slight  Degrees  of  Obesity     .         .         .  28 

II.  Complications  with  Other  Diseases  34 
a.  Diseases  of  the  Circulatory  System  .  34 
h.  Diseases  of  the  Kidneys         ...  42 

c.  Chronic  Pulmonary  Disease        .         .  45 

d.  Chronic  Articular  Rheumatism     .         .  46 

e.  Gout  (Arthritis  urica)         ...  48 
/.  Other  Diseases  of  the  Organs  of  Locomo- 
tion             52 

g.  Diseases  of  the  Nervous  System  .  53 

h.  Diabetes  mellitus  .         .         .         .  54 

i.  Pulmonary  Tuberculosis        ...  56 


NOTE  BY  THE  AMERICAN  EDITOR. 

It  is  due  to  the  disorders  of  metabolism  and  nutri- 
tion that  degenerative  changes  cut  short  the  activities 
of  so  many  men  and  women  in  middle  life, — that,  in 
these  latter  days,  senility  and  death  itself  come  pre- 
maturely to  a  very  large  proportion  of  mankind.  Such 
disorders  constitute  the  bane  of  our  modern  civiliza- 
tion. They  have  been  in  some  measure  also  a  reproach 
to  the  science  and  art  of  medicine,  since  until  very  re- 
cently they  have  not  been  studied  with  a  thoroughness 
commensurate  with  their  importance. 

In  the  series  of  monographs  of  which  this  volume 
on  Obesity  is  the  first,  these  diseases  are  considered  in 
a  manner  which  is  at  once  scientific  and  practical.  They 
are  based  upon  exhaustive  experiments  and  bedside 
observations  carried  out  during  a  period  covering  a 
number  of  years  under  the  direction  of  one  who  is 
eminent  both  as  a  pathologist  and  as  a  clinician. 

In  thus  bringing  together  and  arranging  for  the 
publication  in  convenient  form  ot  the  scattered  writ- 
ings and  reports  of  investigations  by  himself  and  as- 
sistants. Professor  von  Noorden  has  rendered  a  real 
service  to  the  profession  in  both  hemispheres — espe- 
cially now  that  he  has  authorized  the  translation  of  the 
work  into  the  English  language. 


X  INTRODUCTORY  NOTE. 

The  task  of  supervising  the  translation  and  republi- 
cation of  the  series  in  this  country,  undertaken  in  com- 
pliance with  the  personal  request  of  my  friend,  the  dis- 
tinguished author,  has  been  greatly  lightened  by  the 
intelligent  co-operation  of  the  translator.  Dr.  Alfred 
C.  Croftan  of  Chicago,  who  has  rendered  Professor 
von  Noorden's  vigorous,  virile  German  into  smooth 
and  idiomatic  English  while  still  preserving  faithfully 
the  spirit  of  the  original. 

BoARDMAN  Reed, 
1833  Chestnut  Street,  Philadelphia. 


OBESITY;  THE  INDICATIONS  FOR  REDUC- 
TION CURES. 

Introductory. 

Gentlemen :  The  physician  who  does  not  wish  to 
treat  his  patients  according  to  old-established  routine 
practice,  and  who  does  not  feel  satisfied  with  prescrib- 
ing in  a  purely  superficial  manner  (so-called  "expect- 
ant treatment")  will  consider  it  his  duty  and  will  make 
it  a  general  guiding  principle  in  the  treatment  of  his 
cases  never  to  advise  therapeutic  measures  of  any  kind 
without  having  first  decided  to  what  extent  they  are 
justified  and  what  results  may  be  expected  from  them. 
Self  evident  as  these  postulates  may  appear  they  are 
nevertheless  frequently  violated,  particularly  in  the 
treatment  of  chronic  diseases;  chronic  disorders  of 
metabolism  and  of  nutrition,  especially,  are  frequently 
treated  in  a  very  careless  and  superficial  manner  with- 
out any  clear  ideas  apparently  on  the  part  of  the  physi- 
cian in  regard  to  the  exact  indications  obtaining  in 
each  individual  case.  It  seems  almost  incredible  to 
contemplate  how  many  physicians  display  a  very  shal- 
low appreciation  of  the  art  of  healing  when  they  send 
diabetics  and  patients  suffering  from  gall-stones  to 
Carlsbad  or  Neuenahr,  rheumatic  cases  to  Wies- 
baden, sufferers  from  heart  disease  to  Nauheim,  purely 
as  a  routine  practice ;  when  others  habitually  prescribe 
milk  for  cases  of  nephritis  and  interdict  the  use  of 


12         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

meat  to  sufferers  from  renal  disease,  or  attempt  to 
make  the  lean  fat  and  the  fat  lean,  etc.,  always  without 
any  clear  conception  of  what  they  are  doing.     This 
schematic  method  of  treating  certain  chronic  forms 
of  disease  is  encouraged  by  the  elaboration  into  the 
smallest  detail  of  many  so-called  ''methods  of  cure"; 
this  whole  system  of  therapy  would  actually  appear 
lidiculous  if  unfortunately  harm  were  not  done  in  so 
many  cases ;  when  a  medical  history  of  our  times  comes 
to  be  written  in  the  future  we  will  certainly  be  accused 
of  having  endorsed  almost  any  method  of  treatment 
that  seemed  to  contain  something  new  or  seemed  to 
present  certain  special  features;  many  physicians  and 
many  so-called  "enlightened"  laymen  unquestionably 
merit  this  reproof  for  they  seem  to  adopt  any  such 
method  of  treatment  without  first  attempting  to  render 
critical  judgment  on  its  merits  and  demerits.     As  a 
matter  of  fact,  however,  it  would  be  wrong  to  identify 
this  unfortunate  tendency  with  the  trend  of  modern 
scientific  medicine.    On  the  contrary  we  are  fully  justi- 
fied in  saying  that  the  principle  to  avoid  all  dogmatism 
and  all  schematic  methods  is  apparent  to-day  in  mat- 
ters therapeutic  and  that  the  tendency  is  apparent  to 
strictly  individualize,  as  far  as  that  is  possible,  in  the 
treatment  of  the  class  of  disorders  we  are  discussing. 

There  is  always  danger  in  ''individualizing"  for  we 
may  lose  sight  of  the  broad  guiding  principles  that 
should  govern  all  therapy,  and  become  swamped  in  a 
mass  of  detail;  in  order  to  avoid  this,  certain  broad 
points  of  view  should  be  adopted.     It  is  necessary  to 


OBESITY. 


13 


learn  to  distinguish  the  essential  from  the  non-essen- 
tial. It  is  important  above  all  to  know  what  we  are 
trying  to  combat,  why  we  are  combating  it  and  what 
we  expect  to  accomplish  by  the  method  of  procedure 
that  we  adopt.  The  determination  of  all  these  factors 
coincides  with  the  "indications"  for  certain  therapeutic 
measures. 

In  preparing  the  part  on  "Obesity"  for  Nothnagel's 
Handbook  of  Special  Pathology  and  Therapy,  I  was 
struck  by  the  fact  that  none  of  the  many  writings  on 
Obesity  that  have  appeared  in  the  course  of  the  last 
decades  contain  a  comprehensive  elaboration  of  the  in- 
dications for  reduction  cures  in  this  disease.  I  consider 
it  a  grateful  task,  therefore,  to  discuss  the  most 
important  principles  that  should  guide  us  in  institut- 
ing such  reduction  cures  from  a  uniform  point  of  view. 
In  order  to  render  correct  judgment  in  regard  to  the 
advisibility  of  instituting  reduction  treatment  in  any 
given  case  it  is  essential  to  understand  these  deter- 
mining principles  and  to  interpret  them  correctly. 

Before  beginning  treatment  of  any  kind  in  an  obese 
subject  it  is  always  necessary  in  the  first  place  to  de- 
cide the  question  whether  or  not  to  institute  a  so-called 
reduction  cure  or  whether  to  content  oneself  with  pre- 
venting the  further  deposit  of  fat  and  with  pre- 
venting or  removing  disturbing  and  dangerous  com- 
plications. It  will  frequently  be  found  that  the  physi- 
cian and  the  patient  entertain  different  views  on  this 
subject.  Reduction  cures  have  become  so  popular  that 
many  patients  undergo  a  course  of  treatment  of  this 


H 


DISORDERS    OF    METABOLISM    AND    NUTRITION. 


kind  on  their  own  accord  and  without  consulting  a 
physician;  others  merely  consult  a  physician  in  order 
to  learn  the  correct  measures  to  be  adopted  for  the 
purpose  they  have  in  view  but  not  in  order  to  find 
out  whether  a  reduction  cure  is  necessary  or  indicated ; 
still  others  do  not  consult  a  physician  at  all  but  sim- 
ply begin  a  reduction  cure  on  their  own  responsi- 
bility and  according  to  their  own  method.  Frequently 
prescriptions  are  followed  that  are  obtained  from  some 
acquaintance  who  may  claim  to  have  derived  benefit 
from  them,  or  certain  popular  writings  are  consulted 
that  give  the  desired  information  and,  finally,  certain 
watering  places  are  visited  that  enjoy  the  reputation 
in  the  reduction  of  obesity.  This  independence  of  ac- 
tion in  regard  to  the  treatment  of  obesity  we  naturally 
encounter  more  frequently  in  women  than  in  men  and 
more  commonly  in  young  girls  and  in  middle-aged 
women  than  in  older  women.  It  is  often  a  very  dif- 
ficult task  for  the  physician  to  persuade  his  client  of 
either  sex  that  a  reduction  cure  may  be  unnecessary 
or  even  dangerous.  Even  if  we  succeed  in  convincing 
our  patient  for  the  time  being,  the  fight  is  by  no  means 
definitely  won,  for  such  patients  only  too  often  dis- 
cover more  accommodating  advisors  either  among 
physicians  or  in  the  ranks  of  pseudo-physicians. 

We  also  frequently  witness  the  reverse.  A  person 
who  is  too  obese  may  consult  a  physician  for  this  or 
that  trouble  and  the  physician  may  discover  that  the 
symptoms  of  the  patient  are  due  to  excessive  fat  and 
may  advise  a  reduction  cure  on  these  grounds;  the 


OBESITY.  ,5 

patients  on  the  other  hand  merely  recognize  that  they 
are  suffering  from  some  organic  disorder  and  expect 
local  treatment  for  the  relief  of  organic  symptoms; 
they  do  not  understand  how  a  reduction  cure  can  be 
of  any  benefit  nor  how  their  trouble  can  be  relieved 
by  causing  a  loss  of  fat;  in  fact  they  may  refuse  to 
undergo  a  reduction  cure  because  they  fear  the  weak- 
ening effect  of  this  procedure.  In  many  of  these  cases 
we  are  dealing  with  sufferers  from  so-called  ''relative" 
obesity,  in  other  words,  excess  of  fat  according  to 
current  ideas  is  not  great  and  the  patients  themselves 
do  not  regard  themselves  as  "obese" ;  the  physician  on 
the  other  hand  who  studies  all  the  factors  that  are 
operative  in  cases  of  this  character  realizes  how  much 
he  can  benefit  his  patient  by  getting  rid  of  the  excess 
of  fat  and  appreciates  how  much  he  can  improve  the 
functional  powers  of  certain  organs  (for  instance,  the 
heart,  the  lungs,  the  liver,  the  muscles  and  joints) 
by  reducing  the  fat  content  of  the  body. 

What  principles  should  guide  the  physician  in  de- 
ciding for  or  against  a  reduction  cure?  In  the  first 
place  I  wish  to  place  myself  on  record  as  opposing 
the  view,  that  we  hear  so  frequently  expressed,  that 
reduction  cures  are  a  weakening  procedure  and  con- 
stitute, in  other  words,  a  so-called  ''weakening  cure." 
The  ideas  prevalent  in  the  minds  of  the  laity  in  re- 
gard to  this  matter  are  altogether  exaggerated;  a 
perusal  of  the  literature  shows  that  for  many  years 
an  earnest,  but  by  no  means  pleasing,  refreshing  debate 
has  been  waged  on  this  subject;  one  author  will  ad- 


l6         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

vise  this  system  of  dieting  another  that  one.  I  feel 
justified  in  stating  positively  that  a  reduction  cure, 
provided  it  is  really  indicated  and  provided  the  proper 
method  is  adopted  and  carried  out  expeditiously,  is 
by  no  means  a  weakening  procedure,  particularly  if  the 
peculiarities  of  each  individual  case  are  carefully  con- 
sidered in  administering  such  a  cure.  Under  the  con- 
ditions outlined  a  reduction  cure  can  always  be  tol- 
erated without  detriment  to  the  patient  and  as  a  rule 
improves  the  general  functional  powers  of  the  organ- 
ism. It  will  be  seen,  however,  that  such  a  favorable 
judgment  can  only  be  rendered  if  a  series  of  condi- 
tions are  fulfilled  that  sound  simple  enough  but  that 
nevertheless  call  for  careful  consideration  and  pre- 
suppose much  practical  experience  on  the  part  of  the 
physician  who  supervises  the  reduction  cure.  Errors 
are  committed  in  many  of  the  points  that  I  have  men- 
tioned; the  most  frequent  errors  being  those  that  lead 
to  the  adoption  of  a  reduction  cure  when  such  a  method 
of  procedure  is  not  indicated,  and  errors  in  the  method 
itself. 

I  have  already  called  attention  to  the  fact  that  many 
patients  consider  themselves  altogether  competent  to 
decide  the  important  question  whether  or  not  a  reduc- 
tion cure  should  be  instituted ;  this  is  largely  due  to  the 
fact  that  on  superficial  investigation  this  decision 
seems  very  simple  indeed.  In  regard  to  the  method 
I  am  forced  to  confess  that  unfortunately  many  physi- 
cians treat  cases  of  this  kind  according  to  some  pre- 
arranged  scheme  and   not   according  to  the  require- 


OBESITY.  17 

ments  of  each  individual  case  of  obesity.  Here  in 
Germany — and  I  suppose  the  same  obtains  in  other 
countries — we  have  a  number  of  sanatoria  and  many 
physicians  who  are  committed  to  certain  definite  meth- 
ods of  dietetic  treatment,  methods  that  are  usually 
known  by  some  well-known  name;  in  all  such  insti- 
tutions the  particular  method  that  is  in  favor  is  adopted 
for  each  patient  who  goes  there  for  treatment,  and 
all  the  physicians  who  swear  by  any  one  particular 
method  of  treatment  apply  it  in  each  case  that  comes 
under  their  care.  The  method  is  their  idol  and  the 
patient  and  his  disease  are  merely  the  object  on  which 
to  try  the  method.  In  the  whole  field  of  dietetic  thera- 
py this  one-sidedness  and  narrowness  is  nowhere  more 
pronounced  than  in  reduction  cures;  this  unfortunate 
condition  of  affairs  is  the  direct  result  either  of  stu- 
pidity or  of  cheap  and  venial  advertising  that  misleads 
those  who  are  not  competent  to  render  judgment  on 
their  own  accord.  Reduction  cures  are  therefore  a 
happy  hunting  ground  for  the  charlatan  and  the  fakir 
and  for  all  the  exploiters  of  the  "method  swindle." 

How  often  do  we  hear  physicians  say :  In  ordering 
reduction  cures  I  prescribe  the  diet  given  by  Dr.  X., 
or  I  treat  my  cases  according  to  Dr.  Y.'s  method  and 
obtain  the  most  gratifying  results.  This  is  a  very 
one-sided  and  narrow  standpoint  to  occupy  and  it  is 
merely  a  matter  of  luck  if  this  one-sidedness  does  not 
lead  to  the  committing  of  serious  error.  We  pos- 
sess so  many  physical  means  of  treatment  and  such 
a  large  variety  of  dietetic  schemes  that  in  deciding  on 


l8         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

a  method  of  reducing  fat  the  peculiarities  of  each 
individual  patient  can  without  difficulty  be  considered 
and  included  in  the  calculation.  In  numerous  cases, 
it  is  true,  the  choice  of  the  method  is  more  or  less 
indifferent  and  we  may  be  permitted  to  exercise  con- 
siderable latitude,  may  in  fact  allow  the  patient  to  de- 
termine the  method  he  wishes  to  adopt  according  to 
the  requirements  of  the  external  circumstances  obtain- 
ing in  each  case;  in  others  again  the  success  of  the 
treatment  and  the  feasibility  of  instituting  a  reduction 
cure  at  all,  not  to  speak  of  the  well-being  and  the 
very  life  of  the  patient,  may  depend  on  our  choice  of 
method. 


OBESITY. 


19 


I.  Simple  Obesity  in  Otherwise  Healthy 
Subjects. 

The  most  frequent  case  encountered  in  practical  life 
IS  the  development  of  obesity  in  persons  who  are  al- 
together healthy.  The  decision  whether  or  not  to  ad- 
vise a  reduction  cure  in  cases  of  this  character  hinges 
altogether  on  the  degree  of  corpulency  and  on  a  variety 
of  other  external  circumstances  that  differ  in  each  in- 
stance. 

a.  Advanced  Degrees  of  Obesity. — In  deciding 
whether  or  not  a  subject  is  to  be  considered  excessively 
obese  we  must  study  more  the  general  impression 
created  by  the  patient,  both  as  regards  appearance  and 
state  of  health,  than  the  Incubus  of  a  definite  number 
of  kilos  of  fat.  Very  advanced  degrees  of  obesity 
judged  from  this  standpoint  are  almost  without  ex- 
ception fit  subjects  for  a  reduction  cure.  The  dangers 
that  may  arise  if  the  nutritional  disorder  is  allowed 
to  progress  unchecked  are  great  and  it  is  necessary 
to  counteract  this  tendency.  The  restrictions  of  diet 
to  be  imposed  necessarily  vary  with  the  age  of  the 
patient.  In  children  and  young  adults  up  to  the  20th 
year  we  should  be  content  to  arrest  the  further  prog- 
ress of  obesity  and  should  only  at  long  intervals,  that 
is  intermittently,  for  a  period  of  from  four  to  five 
weeks,  make  the  attempt  to  cause  a  definite  loss  of  fat 
(so-called  intermittent  reduction  cures).  All  measures 
aiming  at  a  reduction  of  the  fat-content  of  the  body 
are  essentially  counter-indicated  in  persons  who  have 


20         DISORDERS   OF    METABOLISM    AND    NUTRITION. 

been  obese  all  their  life  or  at  least  for  a  period  of 
several  decades,  particularly  if  they  are  advanced  in 
years  and  are  approaching  old  age ;  here  it  is  necessary 
to  individualize,  for  it  is  impossible  to  say  at  what 
age  senescence  begins;  in  one  subject  this  period  of 
senile  decline  may  be  reached  at  the  age  of  sixty,  in 
others  not  until  seventy  or  eighty.  At  this  period  of 
life  at  all  events  they  begin  to  feel  the  effects  of  ex- 
cessive obesity  more  than  at  earlier  periods;  as  soon 
as  their  vital  energies  begin  to  fail  numerous  disturb- 
ances become  manifest  that  were  never  apparent  in 
earlier  years  when  their  body  was  stronger  and  was 
capable  of  carrying  the  ballast  of  excessive  fat  with- 
out difficulty.  Many  of  these  patients  energetically 
demand  to  be  freed  of  the  unwelcome  burden.  Un- 
fortunately the  correct  time  for  instituting  a  reduction 
cure  has  in  the  majority  of  these  instances  been  al- 
lowed to  elapse  and  a  reduction  cure  instituted  in  a 
subject  suffering  from  beginning  senile  decay  would 
never  more  lead  to  a  rejuvenation  of  the  body.  In 
fact,  reduction-cures  instituted  in  old  persons  almost 
without  exception  accelerate  decay  and  lead  to  a  more 
rapid  loss  of  strength  and  of  functional  powers. 

b.  Medium  Degrees  of  Obesity — (body  weight 
about  15-25  kilo  above  the  average  for  the  particular 
age,  sex  and  size  of  the  subject).  Cases  of  this  kind 
are  the  most  frequent  ones  encountered  and  lend  them- 
selves most  readily  to  treatment  by  reduction  cures; 
they  are  satisfactory  cases  to  treat.  In  many  of  these 
subjects  the  small  excess  of  fat  can  be  borne  with 


OBESITY.  a  I 

impunity  and  in  some  instances  it  may  be  as  well  to 
refrain  from  all  attempts  to  reduce  it;  at  the  same 
time  even  the  small  excess  may  cause  much  discom- 
fort and  it  can  hardly  be  denied  that  intercurrent  dis- 
eases (infectious  diseases,  heart  lesions,  pulmonary 
trouble,  renal  disease,  arthritic  manifestations,  etc. ) ,  or 
over-exertion  (by  over-straining  the  heart),  may  all 
be  frought  with  more  serious  consequences  in  these 
cases  than  if  the  fat  content  were  reduced  to  normal. 

Here,  too,  the  age  of  the  subject  must  be  included 
in  the  calculation,  and  here,  too,  we  must  adhere  strictly 
to  the  rule  that  reduction  cures  should  be  omitted  in 
the  aged  and  should  be  instituted  only  with  the  great- 
est care  and  very  slowly  in  children  and  in  adoles- 
cents. 

The  majority  of  subjects  of  this  kind  are  about 
thirty  years  old  or  still  more  frequently  between  forty 
and  sixty.  The  physician  should  carefully  study  the 
history  of  these  cases  and  should  make  an  accurate 
physical  examination;  if  he  finds  cause  to  fear  the 
development  of  serious  complications  later  on  he 
should  most  emphatically  advise  a  reduction  cure.  In 
cases  in  which  all  the  organs  are  found  to  be  healthy 
the  rapidity  should  be  determined  wdth  which  the  fatty 
deposit  grows;  if  the  fat  deposit  is  increasing  rapidly 
or  even  if  it  is  increasing  slowly  but  steadily  and  pro- 
gressively a  mode  of  life  should  be  arranged  that  will 
favor  arrest  of  this  development;  in  this  w^ay  the  in- 
cidence of  degrees  of  obesity  that  are  directly  dan- 
gerous and  that  offer  a  less  favorable  prognosis  and 


22        DISORDERS    OF    METABOLISM    AND    NUTRITION. 

less  chance  of  success  from  treatment  may  be  prevented 
with  great  profit  to  the  patient.  In  cases  again  in 
which  the  degree  of  obesity  remains  more  or  less  sta- 
tionary the  external  circumstances  of  the  patient  should 
be  considered  before  it  is  decided  whether  or  not  to 
institute  reduction  treatment.  If  the  patients  are  apt 
to  indulge  in  severe  bodily  exercise,  if  they  are  ex- 
posed to  the  dangers  of  alcoholism  or  of  other  dele- 
terious influences  from  excesses  in  living,  if,  finally, 
the  character  and  morals  of  the  patient  seem  to  in- 
dicate that  they  will  not  exercise  moderation  in  work 
and  are  apt  to  over-indulge  in  the  good  things  of 
life,  in  all  these  conditions,  the  fact  must  be  taken  into 
serious  consideration  that  obesity  must  needs  be  dele- 
terious ;  here  a  reduction  cure  should  be  instituted  even 
though  the  patients  are  not  actually  suffering  any  di- 
rect inconvenience  from  their  obesity.  All  the  eventu- 
alities that  we  are  considering  are  more  apt  to  occur  in 
younger  subjects  between  the  age  of  thirty  and  forty, 
that  is  at  the  period,  of  greatest  activity  and  greatest 
physical  and  mental  exertion,  than  in  later  years  of 
life;  in  men,  moreover,  these  deleterious  consequences 
are  more  liable  for  obvious  reasons  to  appear  during 
this  period  than  in  women.  In  all  of  these  cases 
the  success  of  a  reduction  cure  will  depend  essentially 
on  the  length  of  time  during  which  reducing  measures 
are  persevered  in  and  on  the  method  of  reduction  that 
is  employed.  There  is  of  course  no  serious  objection 
to  inaugurating  the  course  of  reducing  treatment  with 
an  energetic  system  of  dietary  and  mechanical  meas- 


OBESITY. 


23 


ures  intended  to  cause  a  quick  loss  of  weight  amount- 
ing to  about  ten  or  fifteen  pounds;  in  fact  it  may  be 
desirable  to  cause  such  a  rapid  loss  of  flesh,  and  no  bad 
effects  have  ever  been  known  to  follow  this  procedure. 
The  root  of  the  matter  is  not,  however,  reached  by 
these  rapid  courses  of  reduction  treatment ;  it  is  much 
more  important,  in  order  tO'  obtain  permanent  and 
lasting  results,  to  induce  the  patient  to  follow  certain 
sensible  rules  at  home  and  to  persevere  in  the  mode 
of  life  that  is  arranged  to  suit  the  peculiarities  of  each 
case  and  the  external  circumstances  in  which  the  pa- 
tient happens  to  be  living;  only  in  this  way  can  an 
increase  of  the  fat  layers  be  prevented  and  can  a  slow 
but  steady  reduction  of  the  excessive  adiposity  be  at- 
tained. Unfortunately  the  majority  of  patients  are 
quite  willing  to  undergo  a  rapid  reduction  cure  but 
rarely  willing  or  able  to  persevere  in  long  lasting  die- 
tetic and  mechanical  restrictions  that  alone  can  lead  to 
the  desired  goal.  Nothing  can  be  more  foolish  or  more 
senseless  than  to  expect  lasting  benefits  from  a  short 
course  of  treatment  every  summer  in  some  watering 
place  as  Marienbad,  Kissingen  or  Homburg,  especially 
if  the  patient  is  allowed  in  the  meantime,  that  is,  dur- 
ing the  remainder  of  the  year  to  live  in  the  customary 
manner  and  free  from  all  restraint  in  regard  to  diet, 
exercise,  etc. ;  the  benefits  derived  from  the  short  sum- 
mer treatment,  lasting  perhaps  a  month  or  so,  do  not 
determine  the  fate  of  the  patient  but  the  results  of  his 
regime  during  the  remaining  eleven  months  of  the 
year.    Unless  the  physician  is  so  fortunate  as  to  secure 


24         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

control  of  the  patient  during  this  longer  period  he  will 
as  a  rule  find  that  the  period  of  involuntary  martyr- 
dom imposed  upon  him  during  the  short  period  of  one 
month  each  summer  is  altogether  devoid  of  lasting 
good  results ;  within  a  few  weeks  after  the  termination 
of  the  cure  and  after  the  patient  by  dint  of  rigid  re- 
strictions in  food  and  drink,  of  violent  purging  and 
of  mountain  climbing  and  forced  gymnastics  has  suc- 
ceeded, painfully  I  may  say,  in  getting  rid  of  a  few 
kilos  of  flesh,  he  will  find  to  his  chagrin  that  the  old 
condition  of  obesity  with  all  the  discomfort  that  it 
entails  will  soon  become  re-established  and  that  his 
vital  energies  continue  to  fail  as  before. 

In  subjects  who  are  perfectly  healthy  and  who  are 
not  exposed  to  particularly  strenuous  and  exhausting 
conditions  in  the  course  of  their  daily  routine  the 
physician  may  proceed  somewhat  differently.  This 
class  of  patients  is  found  chiefly  among  men  of  some- 
what advanced  years  particularly  among  the  wealthier 
class  and  among  professional  people  and  office  workers, 
also  to  a  large  extent  among  women.  In  all  of  these 
cases  there  is  really  no  urgent  indication  for  the  re- 
moval of  moderate  degrees  of  obesity.  People  of  this 
character  who  are  suffering  from  a  slight  excess  of 
flesh  rarely  resign  themselves  to  the  irksome  task  of 
giving  up  some  of  their  favorite  habits  and  of  chang- 
ing their  mode  of  life  for  the  sake  of  getting  rid  of  a 
few  pounds  of  flesh;  they  do  not  care  to  undergo  all 
these  hardships,  to  take  exercise  and  to  deny  them- 
selves many  things  in  order  to  insure  permanent  re- 


OBESITY.  25 

suits;  here,  therefore,  the  sacrifice  is  too  great  and 
the  disadvantages  and  discomforts  accruing  from  such 
a  course  of  treatment  are  altogether  out  of  proportion 
to  the  benefits  to  be  derived  from  the  permanent  loss 
of  five  or  ten  kilos  of  fat.  For  all  these  reasons  we 
frequently  find  that  the  efforts  of  these  people  to  reduce 
their  corpulency  at  home  and  with  the  aid  of  household 
measures  are  essentially  abortive ;  a  brave  attempt  may 
be  made  to  carry  out  the  measures  recommended  but 
the  patients  soon  fall  from  grace  and  give  up  their 
original  intention  of  persevering  with  the  treatment. 
Many  of  these  people  would,  I  believe,  be  quite  will- 
ing to  undergo  a  short  course  of  this  kind  of  treat- 
ment even  if  it  were  very  arduous  and  trying,  pro- 
vided they  could  be  assured  that  the  loss  of  weight 
attained  in  this  way  would  be  permanent  and  that  the 
weapons  could  be  laid  aside  for  all  time  as  soon  as 
the  fight  were  once  won ;  but  we  know  only  too  well  that 
in  order  to  obtain  permanent  results  this  petty  war 
with  one's  own  desires,  tastes  and  inclinations  must 
be  carried  on  daily  and  indefinitely;  very  few  people 
possess  a  sufficient  degree  of  patience  and  energy  to 
persist  in  this  effort;  as  a  rule  few  restrictions,  that 
the  physician  may  have  advised,  are  conscientiously 
carried  out,  unless  of  course  certain  distressing  symp- 
toms warn  the  patient  continuously  not  to  stop  in 
the  treatment  or  unless  the  physician  has  uttered  some 
serious  warning  in  regard  to  life  and  health;  the  ma- 
jority of  people  however  content  themselves  with  some 
one-sided  restriction  that  is  not  particularly  inconveni- 


26         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

ent,  they  stop  drinking  water  during  meals,  for  in- 
stance, or  eliminate  soup  from  the  bill  of  fare,  or  eat 
only  bread  crust  and  none  of  the  inside  of  the  loaf; 
others  take  an  occasional  sweat  bath  or  a  cold  rub  or  go 
to  a  gymnasium  for  half  an  hour's  or  an  hour's  exer- 
cise every  few  days,  or  employ  a  masseur,  etc.  All  these 
measures,  though  only  sham  weapons,  nevertheless  en- 
joy a  great  reputation  with  the  general  public.  Good 
results  are,  of  course,  never  obtained  from  such  half- 
way measures.  Some  five  years  ago  thyroid  prepara- 
tions were  recommended  for  the  reduction  of  fat  and  it 
is  characteristic  for  the  class  of  people  I  have  described, 
(and  I  may  add  that  they  are  chiefly  women  who  lack 
the  energy  and  perseverance  to  carry  out  a  systematic 
reduction  cure,)  that  they  embraced  this  method  of 
treatment  w4th  enthusiasm  because  they  believed  it  to 
be  a  simple  and  convenient  method  of  getting  rid  of  fat 
without  any  exertion  on  their  ow-n  part. 

The  best  method  of  treatment  to  adopt  in  this  class 
of  cases  and  the  one  that  has  been  employed  for  a 
long  time  is  to  institute  short  courses  of  treatment 
lasting  some  four  or  five  weeks  at  varying  intervals; 
the  result  of  these  interrupted  courses  is  a  loss  of 
weight  of  a  few  kilos  (usually  between  three  and 
eight  kilos)  ;  during  this  period,  that  is  after  this  small 
loss  of  flesh  has  been  brought  about,  the  patients  should 
be  induced  to  take  advantage  of  their  comparative  lean- 
ness and  to  strengthen  the  muscles  by  systematic  ex- 
ercises and  at  the  same  time  also  to  strengthen  the 
skin  by  appropriate  measures.     As  a  rule  this  good 


OBESITY.  27 

effect  is  brought  about  by  a  trip  to  some  watering  place 
but  there  is  really  no  reason  wliy  the  same  results 
should  not  be  accomplished  at  home.  In  the  latter  case, 
of  course,  we  cannot  count  so  positively  on  favorable 
results  as  in  the  former ;  if  they  are  sent  to  a  watering 
place  in  fact  we  may  be  almost  sure  of  a  good  result. 
In  the  interval  between  these  short  courses  we  will 
have  to  content  ourselves,  and  are  moreover  probably 
justified  in  contenting  ourselves,  with  eliminating  some 
of  the  most  deleterious  habits  and  with  regulating  the 
general  mode  of  life  of  these  patients  in  such  a  man- 
ner that  the  increase  of  fat  is  not  too  rapid ;  in  this  way 
a  return  to  the  former  state  of  corpulence  may  at  least 
be  retarded. 

I  am  very  much  in  favor  of  sanitarium  treatment 
for  both  classes  of  cases  that  I  have  described,  viz., 
for  sufferers  from  obesity  presenting  urgent  indications 
for  a  reduction  cure  and  for  those  who  do  not;  in 
the  cases  of  medium  degree  a  course  of  treatment  in 
a  closed  institution  is  usually  followed  by  excellent 
results.  The  educational  influence  exercised  by  careful 
and  skilled  physicians  on  patients  afflicted  in  this  way 
is  very  considerable ;  many  patients  who  once  undergo 
such  a  systematic  course  of  sanitarium  treatment  main- 
tain their  reduced  weight,  for  the  reason  chiefly  that 
they  have  learned  to  fully  understand  and  appreciate 
what  they  must  do;  this  applies  even  to  those  cases 
who  live  under  external  circumstances  that  would  or- 
dinarily favor  bad  habits  and  would  necessarily  lead 
to  a  gain  of  flesh  from  neglect  of  the  necessary  pre- 
cautions. 


28         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

If  ordinary  drinking  or  bathing  cures  are  taken 
this  permanent  effect  is  not  as  a  rule  witnessed;  such 
cures,  far  from  educating  patients  in  the  right  direc- 
tion, are  more  apt  to  influence  them  unfavorably.  How 
else  could  we  explain  the  fact  that  thousands  and  thou- 
sands of  these  people  are  forced  to  undergo  a  course 
of  treatment  not  once  or  twice  but  for  ten  or  even 
fifteen  or  twenty  years  in  succession;  these  are  the 
people  whom  we  find  making  an  annual  pilgrimage 
to  Marienbad  or  Karlsbad. 

To  judge  from  my  personal  experience  in  the  treat- 
ment of  these  cases  I  should  say  that  with  rare  ex- 
ceptions the  relapses  that  are  so  frequent  after  or- 
dinary drinking  or  bathing  cures  do  not  occur  if  the 
patients  undergo  a  systematic  course  of  dietetic  treat- 
ment in  a  sanitarium — either  together  with  a  drinking 
cure  or  without  it. 

c.  Slight  Degrees  of  Obesity  (body  weight  about 
5-15  kilo  above  the  normal  average).  Cases  of  this 
character,  provided  the  patients  are  otherwise  healthy, 
do  not  call  for  reduction  treatment;  all  they  require, 
if  their  corpulence  continues  to  increase,  is  treatment 
directed  towards  preventing  a  further  increase  of  fat. 
Nevertheless  many  people,  in  particular  women,  seek 
the  advice  of  a  physician  for  the  sake  of  reducing  even 
these  mild  degrees  of  obesity;  they  want  to  lose  weight 
and  want  to  have  more  slender  figures.  As  a  rule  van- 
ity is  the  chief  reason  why  these  women  want  to 
undergo   reduction   treatment   and  not   physical   dis- 


OBESITY. 


29 


comfort  of  any  kind.  Vanity  plays  a  much  more 
important  role  in  these  cases  than  in  the  more  ad- 
vanced degrees  of  obesity,  for  the  patients  of  both  sexes 
who  are  already  pretty  corpulent  are  usually  accus- 
tomed to  being  obese  and  no  longer  indulge  the  hope 
of  being  able  to  regain  the  slender  outlines  that  they 
possessed  in  more  youthful  years.  Those  who  may 
be  puritanically  inclined  might  object  that  a  physician 
should  not  lend  himself  to  gratifying  the  whims  of 
vanity;  such  an  ideal  standpoint  is  not  justified,  how- 
ever, for  it  does  not  consider  the  actual  exigencies  of 
every  day  practical  life ;  a  physician  who  would  refuse 
to  treat  a  case  of  the  kind  described  on  such  grounds 
would  merely  drive  his  client  into  the  hands  of  some 
quack  who  could  readily  inflict  serious  damage.  Many 
a  physician  will,  in  fact,  welcome  the  opportunity  of 
undertaking  the  treatment  of  such  a  case  because  in  this 
way  he  gains  control  over  the  mode  of  life  of  his 
patients  and  may  exercise  a  beneficial  influence  in  many 
directions,  particularly  as  there  is  usually  much  to  cor- 
rect; he  may  be  able  to  advise  greater  moderation  in 
eating  and  may  regulate  the  time  of  eating  and  the 
use  or  abuse  of  alcoholic  liquors;  again  he  can  give 
definite  directions  in  regard  to  the  amount  of  physical 
exercise  that  should  be  taken;  if  by  dint  of  all  this 
control  and  regulation  of  the  mode  of  life  the  goal  that 
both  physician  and  patient  are  aiming  at  is  finally  at- 
tained, much  more  true  benefit  accrues  to  the  patient 
than  if  a  rapid  reduction  cure  is  undertaken.  Par- 
ticularly in  the  case  of  young  persons  should  rapid 


30 


DISORDERS    OF    METABOLISM    AND    NUTRITION. 


reduction  cures  only  be  advised  with  great  care  and 
after  due  deliberation,  especially  as  it  will  be  found 
that  such  rapid  methods  of  treatment  are  exceedingly 
popular.  All  that  can  be  attained  by  this  method 
of  treatment  is  a  transitory  effect ;  unless  the  gen- 
eral mode  of  life  is  sensibly  regulated  at  the 
same  time  it  never  prevents  the  gradual  transi- 
tion of  mild  forms  of  obesity  into  more  advanced 
degrees.  On  the  other  hand  it  may  be  consid- 
ered established  that  a  careful  avoidance  of  certain  er- 
rors of  living  and  of  diet,  as  for  instance  a  restriction  of 
sweets,  moderation  in  beer  drinking,  a  plentiful 
amount  of  physical  exercise,  will  be  of  infinite  value 
in  the  reduction  of  incipient  obesity  and  will  at  the 
same  time  prevent  the  subsequent  development  of  ex- 
cessive corpulency.  If  therefore  we  can  use  the  vanity 
of  our  patients  as  a  lever,  so  much  the  better;  this 
sort  of  vanity  is  moreover  to  a  certain  extent  excusable 
and  is  by  no  means  so  serious  a  vice  as  many  of  our 
puritanical  friends  would  have  us  believe. 

On  the  other  hand,  of  course,  we  should  exercise 
great  care  in  humoring  the  peculiar  whims  and  fancies 
that  we  occasionally  encounter  in  our  lady  patients.  In 
many  women,  particularly  if  they  have  given  birth 
to  numerous  children,  the  distribution  of  fat  does  not 
occur  regularly  over  the  whole  body  but  seems  to 
favor  the  abdominal  walls  in  particular.  This  is  an 
evil  that  many  women  emphatically  demand  to  have 
remedied  and  unfortunately  it  is  by  no  means  an  easy 
matter  to  do  this.    Reduction  cures  can  of  course  only 


OBESITY.  31 

be  directed  towards  reducing  the  general  fat-content  of 
the  body  and  as  a  rule — though  not  always — produce 
a  loss  of  fat  in  other  parts  of  the  body  than  the  ab- 
domen (the  neck,  the  shoulders,  the  breasts  and  the 
calves  of  the  leg),  while  at  the  same  time  the  fatty 
deposit  in  the  mesentery  and  the  abdominal  walls  per- 
sists with  considerable  obstinacy.     This  peculiar  ef- 
fect   is    seen    particularly    in    rapid    reduction    cures, 
whereas  in  slow  reduction  cures  the  loss  of  fat  is  much 
more  uniform  and  the  loss  of  abdominal  fat  is  con- 
sequently also  greater  in  proportion.     If  the  loss  of 
fat  can  be  maintained  for  some  time  an  equalization 
of  the  different  fat  deposits  occurs,  in  the  sense  namely, 
that  the  excess  of  fat  contained  in  the  abdomen  is 
gradually  transported  to  other  portions  of  the  body 
where  there  is  less  fat.     This  event  is  usually  hailed 
with  much  delight  particularly  as  it  may  follow  within 
a  few  weeks  after  the  institution  of  a  reduction  cure. 
But  the  loss  of  fat  is  by  no  means  an  unmixed  good 
for  in  many  cases  these  women  begin  to  complain  of  a 
series  of  disturbances  that  can  be  directly  attributed 
to  the  loss  of  abdominal  fat ;  they  begin  to  suffer  from 
constipation,  develop  hernias,  gastroptosis,  dislocation 
of  the  kidneys   and  occasionally  malposition  of  the 
uterus ;  the  direct  effects  of  the  loss  of  fat  are  therefore 
in  many  cases  more  troublesome  to  bear  than  the  mild 
degree  of  obesity  that  these  patients  were  formerly 
afflicted  with.     Another  sequence  of  reduction  cures 
in  many  of  these  subjects  is  the  development  of  attacks 
of  gall-stone  colic,  a  condition  that  may  never  have 


32         DISORDERS   OF   METABOLISM    AND    NUTRITION. 

been  noticed  before  or  that  had  at  least  been  dormant 
and  that  can  as  a  rule  be  directly  referred  to  the 
changes  brought  about  in  the  arrangement  and  position 
of  the  intra-abdominal  organs ;  while  the  patients  were 
fat  the  adipose  layer  around  the  gall-bladder  and  the 
liver  protected  these  organs  from  the  pressure  exercised 
by  skirtbands,  corsets,  etc. ;  as  soon  as  the  fat  was 
lost  the  liver  was  readily  compressed  and  the  flow  of 
bile  interfered  with. 

All  these  disadvantages  of  reduction  cures  are  in 
my  experience  more  frequent  in  mild  cases  of  obesity 
than  in  more  advanced  degrees  of  corpulency.  In  cases 
of  pronounced  obesity  reduction  cures,  if  carried  out 
sensibly,  rarely  produce  so  marked  a  loss  of  fat  that 
serious  changes  of  intra-abdominal  pressure  are 
brought  about;  enough  fat  is  usually  allowed  to  re- 
main to  protect  the  abdominal  viscera  and  to  prevent 
excessive  external  pressure  on  these  organs. 

Occasionally  we  are  able  to  promote  a  more  uniform 
loss  of  fat  and  a  participitation  of  the  abdominal  fat 
in  the  general  reduction  by  instituting  a  course  of 
abdominal  massage  together  with  the  reduction  cure. 
The  efficacy  of  this  mode  of  combined  treatment  is, 
however,  greatly  exaggerated.  If  many  women  ac- 
tually have  the  abdomen  massaged  for  a  number  of 
years,  the  long  duration  of  this  treatment  alone  speaks 
against  its  efficacy.  In  cases  in  which  benefits  are 
derived  from  this  method  we  must  assume  that  the 
intestine  is  favorably  influenced,  particularly  in  those 
cases  in  which  a  reduction  of  the  abdominal  circum- 


OBESITY.  33 

ference  is  really  brought  about;  we  know  that  many 
cases  of  obesity  suffer  from  intestinal  atony  and  that 
this  sluggish  condition  of  the  bowels  moreover  is  par- 
ticularly apt  to  follow  reduction  cures;  massage  of 
the  abdomen  undoubtedly  relieves  this  condition  much 
more  than  it  reduces  the  abdominal  fat ;  many  massage 
cranks,  of  course,  both  among  physicians  and  the 
laity,  claim  that  the  method  of  treatment  exercises 
its  primary  and  chief  effect  on  the  abdominal  fat  per 
se.  I  once  attempted  to  determine  the  effect  of  local 
massage  on  local  fat  deposits  and  ordered  daily  mas- 
sage of  one  arm  in  a  stout  lady;  massage  was  given 
according  to  all  the  rules  of  the  art  for  a  period  of 
six  weeks,  a  treatment  every  day.  The  result  was  that 
the  arm  that  was  massaged  gained  one  and  a  half 
centimeters  in  circumference  while  the  other  arm  that 
was  not  massaged  retained  its  old  dimensions. 

If  we  summarize  all  that  has  been  said  in  this  para- 
graph we  arrive  at  the  conclusion  that  reduction  cures 
are  not  urgently  indicated  in  mild  degrees  of  obesity 
but  are  nevertheless  desirable  for  a  variety  of  external 
reasons  and  for  the  purpose  chiefly  of  preventing  the 
development  of  more  advanced  degrees  of  corpulency. 

Of  the  different  methods  of  reducing  treatment  that 
can  be  adopted,  slow  methods  are  unquestionably  to  be 
preferred,  particularly  in  women  with  large  fat  deposits 
in  the  abdomen,  and  in  young  subjects. 


34         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

II.  The  Indications  for  Reduction  Cures  in 
Obesity  Complicated  with  Other  Diseases. 

Diseases  of  various  kinds,  from  mild  functional  dis- 
orders of  important  organs  to  serious  anatomic  lesions 
may  determine  the  attitude  the  physician  should  take 
toward  the  question  of  reduction  cures  in  obesity.  Sim- 
ple and  clear  as  the  matter  lies  in  uncomplicated  obesity 
the  question  becomes  difficult  and  complicated  in  obes- 
ity combined  with  other  diseases.  Generally  speaking 
we  more  often  are  confronted  with  the  necessity  of 
combating  obesity  for  the  sake  of  influencing  the  course 
of  complicating  diseases  than  of  treating  obesity  for  its 
own  sake.  It  is  quite  impossible  to  discuss  all  the 
points  of  view  that  have  to  be  considered  in  this  place 
for  in  order  to  do  this  it  would  be  necessary  to  discuss 
nearly  the  whole  field  of  pathology.  I  must  limit  my 
dissertation  therefore  to  a  discussion  of  the  most  im- 
portant features  of  the  question  at  issue  and  can  only 
treat  of  the  most  important  disturbances  that  should 
induce  us  to  institute  reduction  treatment;  in  this  way 
we  will  learn  to  recognize  those  disorders  that  call  for 
reducing  treatment  even  though  the  degree  of  obesity 
per  se  does  not  apparently  warrant  this  therapy. 

a.  Diseases  of  the  Circulatory  System.  This  class 
of  disorders  is  the  most  important.  Among  them  I 
may  mention  valvular  lesions,  myocarditis,  myodegen- 
eration of  the  heart,  fatty  heart  or  rather  heart  weak- 
ness complicated  with  obesity,  arteriosclerosis,  aneur- 
ysm of  the  aorta,  etc. 


OBESITY. 


35 


When  Oertel  treated  of  the  therapy  of  diseases  of  the 
circulatory  apparatus  together  with  obesity  in  the 
Handbook  of  General  Therapy,  this  was  in  reality  a 
very  one  sided  standpoint  to  occupy ;  at  the  same  time 
this  classification  of  the  subject  has  since  been  shown 
to  be  of  the  greatest  practical  importance  and  at  the 
same  time  of  considerable  historical  interest  and  sig- 
nificance. Oertel  argued  that  the  treatment  of  these 
two  classes  of  disorders  was  inseparably  connected. 

Even  before  Oertel's  day  the  dangers  of  obesity  in 
heart  disorders  were  clearly  recognized  (for  instance 
in  the  prognosis  of  acute  infectious  diseases,  pneu- 
monia, typhoid  fever,  etc.),  but  no  one  stated  the 
dangers  arising  for  heart  cases  when  they  were  compli- 
cated by  obesity  so  emphatically  as  did  Oertel,  and  no 
other  writer  so  forcibly  described  the  great  advantages 
accruing  to  heart  cases  thus  complicated,  from  thera- 
peutic measures  directed  towards  a  reduction  of  ex- 
cessive fat.  We  may  even  say  that  on  the  contrary 
many  clinicians  before  Oertel  considered  reduction 
cures  harmful  in  heart  disease  because  they  believed 
that  such  treatment  had  a  weakening  effect  on  the 
organism,  and  should  not  be  instituted  in  heart  cases. 
If  I  speak  of  heart  cases  in  this  place  I  do  not  refer 
merely  to  sufferers  from  heart  lesions  proper,  from 
valvular  disorders,  and  from  diseases  of  the  heart  mus- 
cle, but  to  all  patients  who  are  afflicted  with  diseases 
that  impose  increased  work  on  the  heart  as,  for  in- 
stance, patients  with  arteriosclerosis,  kyphoscoliosis, 
advanced  degrees  of  emphesematous  destruction  of  pul- 


3D         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

monary  capillaries,  extended  adhesive  pleuritis,  etc. 
All  these  cases  have  this  in  common  that  the  heart  is 
forced  to  perform  increased  and  excessive  work  and 
is  soon  brought  into  a  condition  of  hypertrophy  with 
danger  of  dilatation  and  insufficiency  of  the  heart  mus- 
cle, etc.  The  deleterious  effects  on  the  heart  are  in- 
creased whenever  the  body  carries  an  excessive  ballast 
of  fat.  The  greater  this  ballast  the  greater  the  de- 
mands on  the  heart  and  the  smaller  the  surplus  of  en- 
ergy at  the  disposal  of  the  heart  musculature  for  over- 
coming the  pathologic  obstacles  to  the  circulation  of  the 
blood. 

As  a  rule  it  is  altogether  impossible  to  exercise  any 
direct  effect  on  the  lesions  of  the  circulatory  apparatus 
itself;  how  should  it  be  possible,  for  instance,  to  dilate 
a  stenosis  of  the  cardiac  orifices  or  to  re-establish  the 
permeability  of  obliterated  pulmonary  capillaries  ?  In 
cases,  however,  that  are  complicated  with  obesity  we 
can  successfully  combat  the  latter  condition  and  by  re- 
lieving it  save  the  heart  a  great  deal  of  excessive  work, 
and  in  this  way  enable  the  impaired  organ  to  devote  all 
its  surplus  energy  to  combating  the  irremediable  effects 
of  the  pathologic-anatomic  disturbance  with  the  circu- 
lation of  the  blood-stream.  These  theoretic  consider- 
ations have  been  brilliantly  corroborated  by  practical 
experience.  To  judge  from  all  the  reports  of  numerous 
writers,  and  I  may  include  a  large  clinical  experience 
of  my  own,  reduction  cures  instituted  in  a  correct  man- 
ner constitute  one  of  the  most  valuable  adjuvants  to  the 
treatment  of  circulatory  diseases  that  we  possess. 


OBESITY. 


37 


There  are,  of  course,  numerous  cases  in  which  the 
degree  of  obesity  is  so  great  or  in  which  the  lesions  of 
the  circulatory  apparatus  are  so  far  advanced  that  it  is 
altogether  impossible  to  restore  the  heart  to  its  normal 
functional  activity. 

The  most  satisfactory  and  the  most  suitable  cases 
for  reduction  treatment  are  those  in  which  slight  dis- 
orders of  the  circulatory  apparatus  are  present,  that  are 
very  well  compatible  with  life,  and  at  the  same  time 
moderate  degrees  of  obesity,  cases  in  which  the  first 
signs  of  failing  compensation  are  just  beginning  to  ap- 
pear; these  constitute  the  majority  of  cases  of  heart 
disease  that  present  themselves  for  treatment.  If  in 
patients  of  this  character  the  one  damaging  factor, 
viz.,  obesity,  is  excluded,  and  if  in  addition  other  meas- 
ures are  instituted  that  strengthen  the  heart,  many 
years  of  life,  even  many  decades  of  comparative  w^ell- 
being,  may  be  granted  these  sufferers. 

The  results  of  this  plan  of  treatment  are,  of  course, 
still  more  positive  if  the  first  signs  of  failing  compen- 
sation are  not  even  allowed  to  appear,  and  if  in  all 
cases  that  are  afflicted  even  with  slight  disorders  of  the 
circulatory  apparatus  all  excessive  fat  is  gradually  re- 
moved, or  if  not  removed  at  least  prevented  from  in- 
creasing so  as  to  lead  to  more  advanced  degrees  of  obes- 
ity. This  is  a  particularly  good  field  for  prophylaxis 
and  it  must  be  considered  one  of  the  most  important 
duties  of  the  family  physician  to  carefully  prevent  the 
incidence  of  obesity  in  all  cases  that  come  under  his 
care  in  which  he  recognizes  some  weakness  of  the  cir- 


38  DISORDERS    OF    METABOLISM    AND    NUTRITION. 

culatory  apparatus,  as,  for  instance,  some  valvular 
lesion  developing  in  early  years ;  in  all  cases  of  this  kind 
he  must  know  and  understand  that  obesity  is  a  most  un- 
desirable and  a  dangerous  complication. 

The  peculiarities  of  each  individual  case  must,  of 
course,  determine  the  exact  modus  operandi  to  be  pur- 
sued in  combating  the  tendency  to  obesity.  A  few 
general  points  of  view  can  nevertheless  be  established. 

In  hopeless  cases  that  offer  no  chance  of  recovery  it 
is,  of  course,  useless  to  institute  a  reduction  cure.  It 
is  well,  however,  not  to  draw  the  line  too  closely  in 
this  respect,  and  not  to  declare  too  many  cases  as  be- 
yond repair.  It  will  be  found  that  in  the  different 
forms  of  impairment  of  the  heart,  of  heart  weakness, 
that  we  encounter  in  obese  subjects,  better  results  are 
as  a  rule  obtained  than  in  simple  cases  of  heart  lesions ; 
effects  are  sometimes  produced  that  could  hardly  be 
foreseen.  I  consider  those  cases  grave  in  which  ede- 
ma is  present  and  in  which  attempts  to  treat  the  case 
energetically  with  digitalis  and  similar  remedies  have 
been  abortive.  In  all  such  cases  danger  is  threatening. 
Although  naturally  no  one  will  for  one  instant  consider 
the  advisability  of  instituting  a  regular  dietetic  reduc- 
tion cure  in  cases  of  this  character,  we  must  never  for- 
get that  in  all  such  patients  the  diet  is  reduced  any- 
how even  without  our  suggestions  to  reduce  the  amount 
of  food ;  in  fact,  we  will  rarely  succeed  in  inducing  pa- 
tients of  this  kind  to  eat  much;  these  cases  always  de- 
velop thirst  but  at  the  same  time  have  a  considerable 
aversion  for  solid  food.     The  only  measure  that  prom- 


OBESITY.  ^Q 

ises  some  success  in  these  desperate  cases  is  a  limita- 
tion of  the  amount  of  Hquid  nourishment  combined 
with  the  administration  of  strong  heart  stimulants  like 
camphor,  ether,  strong  spirituous  liquors,  etc.  It  is  fre- 
quently a  difficult  matter  to  carry  out  this  limitation  of 
liquid  pabulum  but  it  is  worth  while  to  make  the  at- 
tempt ;  for  in  all  cases  that  can  be  helped  at  all  we  will 
witness  distinct  signs  of  improvement  within  a  week  or 
two.       As  soon  as  all  immediate  danger  is  passed  we 
should  begin  to  strengthen  the  heart  with  careful  gym- 
nastic exercises  and  hydrotherapeutic  measures.       I 
think  that  Schott  was  right  when  he  called  attention  to 
the  fact  some  years  ago  that  many  obese  subjects  derive 
marked  benefits  from  this  method  of  treatment  even  in 
apparently  desperate  cases.     As  soon  as  the  first  fa- 
vorable results  are  obtained  we  should  always  follow 
the  treatment  up  with  a  second  course  of  digitalis  and 
we  will  as  a  rule  find  that  now  the  results  of  this  ther- 
apy are  much  more  favorable  than  they  were  before. 
As  soon  as  the  powers  of  the  heart  are  improved  the 
appetite  too  as  a  rule  increases.     It  would  be  altogether 
wrong  to  limit  the  amount  of  food  at  this  period  for 
fear  of  increasing  the  fat  deposit;  the  appetite  of  the 
patient  should  therefore  not  be  reduced  but  should  be 
welcomed  as  a  sign  of  improvement.     As  a  matter  of 
fact,  patients  who  have  just  recovered  from  a  severe 
heart  attack  should  be  allowed  a  liberal  diet  which,  of 
course,  must  be  carefully  administered  and  arranged 
in  such  a  manner,  as  regards  quality  and  quantity,  as 
not  to  overload  the  digestive  organs.     Not  until  all  im- 


40         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

mediate  danger  of  renewed  heart  weakness  is  elimin- 
ated should  we  begin  to  impose  restrictions  in  regard 
to  the  diet,,  and  not  until  then  should  we  think  of  ad- 
vising a  reduction  cure  proper;  at  the  same  time  we 
should  not  allow  the  most  favorable  period  for  this 
treatment  to  elapse,  and  should  certainly  not  omit  this 
method  of  therapy  altogether,  for  otherwise  we  may 
expect  to  witness  the  development  of  renewed  attacks  of 
cardiac  insufficiency.  If  it  can  be  done  at  all,  patients 
of  this  kind  should  be  treated  clinically  as  long  as  there 
is  any  danger  from  this  source. 

The  matter  is  much  more  simple  and  more  favorable 
in  regard  to  the  final  outcome  if  the  disturbances  of 
compensation  are  just  beginning,  regardless  of  whether 
they  are  due  to  fatty  heart  {Mast-F either z,  Kisch)  or 
to  some  complicating  organic  lesion  of  the  heart  or  the 
blood  vessels.  The  best  way  to  begin  treatment  is  to 
give  digitalis  for  a  time;  it  appears  to  me,  that  in  cases 
of  this  kind  in  particular,  large  doses  of  digitalis  con- 
tinued for  a  long  period  are  thoroughly  indicated ;  this 
method  of  treatment  has,  of  course,  been  recommended 
for  some  time  by  other  clinicians  than  myself,  in  parti- 
cular by  the  physicians  in  Nauheim  (Groedel).  Fol- 
lowing such  a  course  wdth  digitalis  a  rapid  reduction 
cure  should  be  instituted;  none  of  those  methods  of 
treatment,  however,  should  be  employed  that  call  for 
the  administration  of  strong  laxatives.  In  view  of  the 
condition  of  the  heart  only  small  quantities  of  liquid 
should  be  allowed  these  patients.  Whenever  I  en- 
counter a  patient  in  this  stage  of  the  disease  I  greatly 


OBESITY. 


41 


prefer  continuing  the  treatment  in  a  sanitarium  be- 
cause the  results  obtained  in  institutions  are  so  much 
better  than  those  commonly  obtained  at  home;  in  fact, 
the  effects  of  such  a  cure  may  be  excellent  and  quite 
surprising.  As  soon  as  the  first  good  effects  are  ob- 
tained it  is  always  well  to  proceed  more  slowly. 
In  the  beginning  we  may  cause  a  loss  of  four  or  five 
pounds  a  week,  but  later  the  same  amount  of  flesh 
should  be  sacrificed  only  each  month. 

In  all  of  these  cases  intermittent  reduction  cures  are 
also  thoroughly  indicated  and  lead  to  the  goal;  this 
treatment  is  carried  out  as  follows : — In  the  beginning 
we  should  content  ourselves  with  bringing  about  a  loss 
of  about  ten  pounds,  then  the  patient  is  again  allowed 
to  partake  of  a  somewhat  more  liberal  diet  so  that  no 
more  fat  is  lost  but  at  the  same  no  fat  is  gained ;  at  the 
expiration  of  about  a  month  the  diet  is  again  limited 
and  a  loss  of  flesh  produced,  and  so  on.  Together  with 
reduction  cures  other  measures  should  be  instituted 
that  are  intended  to  increase  the  muscular  powers  of 
the  patient  (exercise  treatment  in  Oertel's  sense,  even 
though  not  always  according  to  his  methods)  ;  in  addi- 
tion the  patient  should  be  given  cold  rubs,  sitz  baths, 
douches,  mud  baths,  in  particular  carbonated  mud 
baths,  in  order  to  stimulate  the  peripheral  circulation. 
The  physician  should  continuously  study  the  best 
methods  for  arranging  the  mode  of  life  of  the  patient 
in  such  a  manner  that  the  increase  of  fat  is  prevented. 
The  loss  of  fat  should  in  time  be  carried  so  far  that  the 
patient  regains  his  normal  w^eight;  in  the  beginning 


42         DISORDERS   OF    METABOLlSxM    AND    NUTRITION. 

the  reduction  of  flesh  should  proceed  rapidly,  later  more 
slowly. 

In  cases  of  heart  disease  in  which  no  compensatory 
disturbances  have  made  their  appearances  there  is 
really  no  reason  w^hy  a  rapid  reduction  cure  should  not 
be  instituted,  particularly  in  medium  and  advanced  de- 
grees of  obesity;  in  the  latter  cases  it  may,  in  fact,  be 
difficult  to  get  along  without  rapid  reduction  cures 
repeated  at  varying  intervals.  The  most  important 
part  of  the  treatment,  however,  is  the  regulation  of  the 
general  mode  of  life  of  these  patients  so  that  a  loss  of 
fat  is  slowly  but  surely  brought  about.  The  physician 
should  never  relax  in  his  endeavors  to  call  the  pa- 
tient's attention  to  the  dangers  that  may  arise  from  a 
violation  of  the  rules  he  lays  down.  Even  in  patients 
suffering  from  medium  or  slight  degrees  of  obesity  it 
will  be  found  that  a  knowledge  of  these  dangers  is 
beneficial,  and  the  physician  should  constantly  direct 
their  attention  to  the  disadvantages  accruing  from  neg- 
lect of  the  precautions  laid  down,  for  in  this  way  he 
can  manage  his  patients  much  better.  The  results  of 
all  this  treatment  will,  however,  be  unsatisfactory  and 
incomplete  unless  at  the  same  time  we  institute  meas- 
ures that  are  intended  to  exercise  and  to  strengthen  the 
muscles. 

&.  Diseases  of  the  Kidneys.  The  only  renal  disease 
that  we  must  consider  in  this  connection  is  atrophic 
nephritis.  As  far  as  I  can  see  very  little  attention  has 
so  far  been  bestowed  on  the  prognostic  importance  of 
dietary  treatment  in  patients  with  contracted  kidneys. 


OBESITY.  43 

This  is  surprising,  particularly  as  we  fully  realize  that 
the  fate  of  these  patients  is  to  such  a  large  extent  de- 
pendent on  the  functional  powers  of  the  heart  and  that 
the  heart's  action  is  always  endangered  by  exces- 
sive fat  deposits.  In  the  studies  I  have  made  of  the 
treatment  of  contracted  kidney  (reported  in  sketch  be- 
fore the  Congress  of  Internal  Medicine,  1899),  I  have 
given  particular  attention  to  these  points,  and  I  do  not 
hesitate  to  state  that  in  my  opinion  obesity  is  as  dan- 
gerous for  patients  afflicted  with  contracted  kidney  as 
for  patients  suffering  from  heart  disease,  and  that  pre- 
vention of  obesity,  or  treatment  of  obesity  if  it  exists, 
is  as  beneficial  for  patients  with  atrophic  nephritis  as 
for  heart  cases.  We  are  altogether  unable  to  influence 
the  anatomic  changes  that  have  occurred  in  the  kidneys 
and  that  lead  to  albuminuria,  and  we  are  only  to  a  very 
slight  extent  enabled  to  influence  the  excretion  of  albu- 
men, consequently  all  our  efforts  should  be  directed  to- 
wards the  important  aim  of  upholding  and  strengthen- 
ing the  powers  of  the  heart.  In  order  to  do  this  it  is 
just  as  important  to  combat  any  tendency  to  obesity  as 
it  is  to  reduce  the  amount  of  water  allowed  these  pa- 
tients, a  system  of  protective  therapy  that  I  have  advo- 
cated in  another  place. 

In  general  practice  these  fundamental  principles  are 
frequently  violated.  I  frequently  see  cases  of  atrophic 
nephritis  that  were  formerly  lean  or  in  a  normal  state 
of  weight  fed  on  so  inappropriate  a  diet  (several  liters 
of  milk,  butter,  farinaceous  foods,  bread  and  other 
vegetables)  that  they  soon  become  much  heavier  and 


44         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

may  without  hesitancy  be  called  actually  obese. 
Whereas  these  patients,  notwithstanding  the  existence 
of  albuminuria,  felt  comparatively  well,  they  now  de- 
velop a  variety  of  secondary  disturbances  on  the  part 
of  the  heart,  in  particular  stenocardiac  attacks  that 
may  all  disappear  again  (provided  the  disease  has  not 
progressed  too  far)  as  soon  as  a  considerable  reduction 
of  the  accumulated  fat  is  brought  about. 

I  may  be  permitted  to  sketch  a  case  of  this  kind. 

The  patient  was  an  official  of  40  years,  in  whose 
urine  an  abundant  quantity  of  albumen  was  discovered 
when  he  was  examined  for  life  insurance.  At  the  time 
this  discovery  was  made  he  felt  perfectly  well.  His 
physician  made  the  diagnosis  of  contracted  kidney,  that 
was  undoubtedly  correct,  and  prescribed  a  diet  of  milk 
and  farinaceous  foods,  and  at  the  same  time  prohibited 
the  use  of  meat  and  eggs.  Within  three  months  the 
body  weight  of  this  patient  increased  from  130  to 
170  pounds.  At  the  same  time  the  patient  began  to 
suffer  from  frequent  attacks  of  dyspnea  and  also  de- 
veloped several  mild  sternocardiac  attacks  at  night.  He 
consulted  me  for  the  first  time  when  he  was  in  this  con- 
dition. The  apex  beat  was  found  about  15  centi- 
meters away  from  the  median  line.  The  degree  of 
albuminuria  was  about  0.03  per  cent.,  that  is  about  as 
high  as  it  had  been  at  the  time  when  the  disease  of  the 
kidneys  was  first  discovered  three  months  before  (ac- 
cording to  an  analysis  that  the  patient  submitted,  the 
original  degree  of  albuminuria  was  0.033  P^^  cent.). 
I  prescribed  a  reduction  in  the  amount  of  liquid  nour- 
ishment to  5-4ths  of  a  liter  combined  with  a  diet  that 
contained  few  calories  (about  25  calories  per  kilo) ; 
at  the  same  time  the  patient  was  ordered  to  take  cold 


OBESITY.  45 

rubs  and  later  to  undergo  a  course  of  treatment  in 
Homburg.  The  result  of  this  treatment  was  excellent. 
Within  six  weeks  the  weight  of  the  patient  was  re- 
duced to  about  150  pounds,  and  after  ten  weeks  to  135 
pounds.  The  albuminuria  naturally  persisted  but  all 
the  distressing  subjective  symptoms  disappeared ;  at  the 
same  time  the  apex  beat  was  found  three  centimeters 
nearer  to  the  median  line,  and  the  patient  in  this  way 
escaped  the  danger  of  heart  failure  that  was  imminent. 

I  hope  that  others  may  be  stimulated  to  follow  my 
example  in  treating  cases  of  this  kind  in  this  way  and 
that  more  attention  will  hereafter  be  bestowed  on  the 
circumstances  that  I  have  described.  I  believe  that 
many  cases  of  renal  disease  will  derive  great  benefit 
from  a  careful  regulation  of  the  diet  directed  not  alone 
toward  relieving  albuminuria  but  also  toward  improve- 
ment of  the  general  state  of  nutrition  of  the  patient. 

c.  Chronic  Pulmonary  Disease.  As  it  is  my  inten- 
tion to  discuss  pulmonary  tuberculosis  separately,  and 
as  many  other  disorders  (for  instance,  kyphoscoliosis, 
emphysema,  adhesive  pleurisy)  have  already  been  dis- 
cussed in  the  paragraph  on  obesity  complicated  with 
diseases  of  the  circulatory  apparatus,  I  will  limit  my 
discussion  here  to  chronic  bronchitis.  This  condition, 
in  different  degrees  of  severity  and  in  different  varie- 
ties, is  a  very  frequent  complication  of  obesity.  There 
are  many  cases  of  obesity  that  suffer  from  moderate 
degrees  of  dilatation  of  the  lungs  and  from  recurrent 
bronchitis.  These  are  forced  from  year  to  year  to 
spend  their  summers  in  Ems  and  their  winters  in  south- 
ern climates;  they  take  one  inhalation  cure  after  an- 


46  DISORDERS  OF  METABOLISM    AND    NUTRITION. 

other  and  swallow  the  whole  array  of  solvents ;  many 
of  them  become  constant,  and  by  no  means  welcome, 
visitors  to  different  hospitals  without  ever  deriving 
any  particular  benefit  from  the  different  methods  of 
treatment  they  adopt,  without  ever  being  restored  to 
health,  and,  above  all,  without  being  saved  from  con- 
stant relapses.  However  beneficial  the  one  or  the  other 
method  of  treatment  may  occasionally  be,  these  pa- 
tients are  nevertheless  not  permanently  benefited  until 
the  surplus  fat  is  removed.  As  soon  as  this  is  done 
they  can  perform  deeper  breathing,  can  fill  the  lungs 
and  in  this  way  can  encourage  a  free  circulation  of  the 
blood  stream  through  the  pulmonary  capillaries.  In 
some  of  these  cases  the  condition  of  bronchitis  may 
heal  spontaneously  under  these  circumstances,  in  others 
traces  of  the  old  trouble  remain  behind  but  they  no 
longer  endanger  the  general  health  of  the  patient  to 
such  a  degree,  nor  do  they  become  exacerbated  as  fre- 
quently as  before. 

That  this  is  an  important  matter  can  readily  be  seen ' 
from  the  fact  that  many  cases  of  obesity  perish  from 
respiratory  insufficiency  even  though  the  heart  and  the 
arteries  may  be  quite  normal.  The  limitation  of  the 
intrathoracic  space  by  fat  may  become  so  great  that  an 
attack  of  bronchitis  or  the  exacerbation  of  a  chronic 
bronchial  catarrh  may  precipitate  a  severe  dyspneic 
seizure  or  even  a  fatal  issue  simply  from  interference 
with  the  respiratory  excursions  of  the  lungs. 

d.  Chronic  Articular  Rheumatism.     In  certain  re- 
spects similar  conditions  obtain  in  chronic  arthritis; 


OBESITY. 


47 


this  disease  if  it  attacks  the  intervertebral  articulations, 
the  articulations  of  the  pelvis  or  of  the  legs  favors  obes- 
ity from  the  very  beginning;  patients  afflicted  with 
this  disease  are  only  too  willing  to  take  any  methods 
of  treatment  for  the  cure  of  their  articular  trouble, 
chiefly  for  the  sake  of  relieving  the  pain  in  the  joints 
and  of  changing  the  distorted  appearance  of  the  af- 
fected members;  they  undergo  hot  air  treatment,  or 
steaming,  or  hot  bathing  cures,  or  gladly  go  for  a 
course  of  treatment  to  the  thermal  baths  of  Wiesbaden, 
Nauheim,  Gastein,  Wildbad,  or  to  the  mud  baths  of 
Kissingen,  Marienbad,  Franzensbad,  etc.  These  and 
other  measures  are  without  doubt  at  times  useful  but 
they  are  also  occasionally  superfluous,  so  that  they  can 
very  well  be  dispensed  with.  The  benefits,  however, 
derived  in  many  cases  from  the  reduction  of  obesity 
are  particularly  striking;  in  many  patients,  in  whom 
we  can  produce  a  considerable  loss  of  weight,  we  re- 
move pressure  and  excessive  work  from  the  joints  and 
in  this  way  bring  about  the  same  good  effect  as  ortho- 
pedic surgeons  with  the  ingenious  apparatus  they  have 
devised  for  the  purpose.  I  know  many  cases  of  arthri- 
tis in  which  great  power  of  locomotion  has  been  re- 
gained simply  by  getting  rid  of  some  of  their  fat ;  they 
enjoy  a  freedom  of  motion  that  seemed  lost  forever.  In 
many  of  these  subjects  such  measures  as  baths,  mas- 
sage, etc.,  did  not  begin  to  exercise  any  beneficial  ef- 
fect on  the  arthritic  process  until  a  reduction  cure  had 
first  been  instituted,  and  before  the  loss  of  fat  was 
brought  about  all  the  measures  I  have  mentioned  were 


48         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

altogether  without  favorable  or  permanent  effect.  I 
was  surprised  to  find  that  our  colleague,  Ott,  from 
Marienbad,  failed  to  mention  the  advantages  to  be  de- 
rived from  reduction  cures  in  the  treatment  of  ar- 
thritic subjects.  In  the  report  he  made  to  the  Congress 
of  Internal  Medicine  in  1896  he  failed,  however,  to 
even  mention  the  subject.  In  discussing  this  report  at 
the  time  I  called  attention  to  this  omission. 

e.  Gout  {Arthritis  urica).  It  is  a  well-known  fact 
that  gout  and  obesity  are  frequently  found  together 
in  the  same  individual.  The  prognosis  of  gout  in 
obese  subjects  is  comparatively  favorable;  the  disease 
in  such  subjects  rarely  develops  into  that  more  serious 
form  with  deposit  of  numerous  tophi  and  great  des- 
truction of  articular  structures,  that  is  comparatively 
common  in  lean  persons.  It  is  also  easier  to  attain  good 
results  from  treatment  in  this  class  of  gouty  cases,  for 
here  moderation  in  living  and  extensive  physical  ex- 
ercise are  usually  followed  by  favorable  results.  The 
treatment  of  gout  and  of  obesity  is  therefore  the  same 
in  many  respects.  Reduction  cures  in  gout  intended 
to  influence  both  metabolic  disorders  at  once  have  con- 
sequently been  popular  for  a  very  long  time,  and  form 
one  of  the  most  important  and  the  most  justifiable 
branches  of  the  balneological  treatment  in  Carlsbad, 
Homburg,  Kissengen,  Marienbad,  Vichy  and  other 
places.  In  practice  we  usually  limit  ourselves  to  pre- 
scribing an  annual  course  of  such  balneological  treat- 
ment; in  addition  we,  of  course,  give  a  few  important 
regulations  (interdiction  of  strong  alcoholic  drinks  and 


OBESITY.  j^g 

of  abundant  quantities  of  liquid  nourishment  and  of 
water),  and  a  few  unimportant  ones  (interdiction  of 
dark  meats).  This  method  of  treating  our  cases  is 
without  doubt  correct  and  useful ;  at  the  same  time  we 
would  benefit  them  a  great  deal  more  if  we  attempted 
to  influence  the  general  daily  mode  of  life  to  a  greater 
extent  than  we  are  in  the  habit  of  doing.  We  realize, 
however,  that  particularly  in  these  cases  it  is  a  difficult 
matter  to  convince  the  patients  that  they  are  likely  to 
sacrifice  all  the  benefits  derived  from  a  course  in  Carls- 
bad, etc.,  if  they  immediately  relapse  into  their  ordinary 
mode  of  life.  In  many  patients  of  this  character  who 
are  pampered  and  who  are  used  to  an  easy  way  of  liv- 
ing and  who  do  not  care  to  make  radical  changes  in 
their  mode  of  life,  a  prolonged  course  of  treatment  in  a 
sanitarium  may  be  of  great  benefit,  particularly  in  the 
sense  of  educating  these  people  in  the  correct  manner 
of  living. 

Great  difficulties  are  offered  in  the  selection  of  the 
correct  diet  for  cases  of  gout  complicated  with  obesity. 
If  we  follow  Sydenham's  old  doctrine,  we  will  have  to 
limit  the  amount  of  meat  to  a  great  extent  in  the  treat- 
ment of  gout,  whereas  in  the  treatment  of  obesity  it  is 
not  well  to  reduce  the  amount  of  meat  for  any  length 
of  time.  Without  indorsing  the  theoretic  ideas  ad- 
vanced by  Pfeiffer,  I  nevertheless  agree  with  the  prac- 
tical advice  he  gives  for  the  treatment  of  obese  sufferers 
from  gout,  namely,  not  to  fear  the  effects  of  abundant 
quantities  of  meat  (lean  meats  of  any  kind  or  color) ; 
the  only  precaution  to  be  observed  in  this  practice  is 


so 


DISORDERS   OF    METABOLISM    AND    NUTRITION. 


that  the  patients  are  also  given  a  plentiful  amount  of 
green  vegetables  and  of  fruit  at  the  same  time. 

In  gouty  subjects  we  frequently  find  a  variety  of  dis- 
orders that  call  for  a  reduction  cure  with  much  greater 
urgency  than  the  uric  acid  diathesis  itself.  I  refer  to 
genuine  renal  disease,  arterioslerosis,  attacks  of  cardiac 
weakness,  etc.  Some  writers  have  attempted  to  classi- 
fy the  disturbances  of  the  heart  that  are  seen  in  cases  of 
gout  under  the  heading  of  an  independent  syndrome 
that  they  call  gouty  heart  (Gichtherz,  Th.  Schott). 
Such  a  definition,  it  appears  to  me,  is  altogether  with- 
out justification.  If  we  study  cases  of  this  kind  more 
thoroughly—  '^nd  I  have  occasion  to  see  many  dozen 
such  patients  every  year,  in  great  part  Englishmen  who 
consult  me  when  they  come  from  Nauheim — we  will 
find  that  almost  without  exception  we  are  dealing  with 
obese  subjects  who  combine  distinct  arteriosclerosis 
and  occasionally  slight  albuminuria  with  obesity. 
From  the  history  of  these  cases  we  usually  learn  that 
the  patient  indulged  in  violent  physical  exercise  in  his 
youth  and  lived  a  luxurious  life  later  on  usually  with 
excessive  indulgence  in  alcoholic  liquors.  This  mode 
of  life  we  learn  was  carried  on  until  the  first  symptoms 
of  the  disease  appeared ;  here  we  certainly  have  ground 
enough  for  the  simultaneous  development  of  obesity 
and  of  serious  injury  to  the  circulatory  apparatus.  As 
soon  as  the  slightest  signs  of  gouty  pain  appear  together 
with  these  symptoms,  and  in  innumerable  cases  with- 
out any  definite  indication  of  gout,  the  average  Eng- 
lishman is  inclined  to  attribute  the  whole  symptom  com- 


OBESITY.  51 

plex  to  the  gouty  diathesis  and  to  explain  all  his 
troubles  on  this  basis.  This  view  is  certainly  wrong. 
It  would  be  of  much  greater  benefit  to  every  one  con- 
cerned if  we  refrained  from  using  the  euphemistic  ex- 
pression gout  and  called  things  by  their  right  name.  If 
we  did  this  we  would  not  attribute  the  symptoms  to 
any  gouty  disposition,  but  simply  to  chronic  abuse  of 
alcohol.  From  a  therapeutic  point  of  view  the  doc- 
trine of  gouty  heart  has  been  of  great  benefit.  We 
have  become  accustomed  in  patients  afflicted  in  this 
way  to  consider  the  condition  of  the  heart  more  than 
the  uratic  diathesis  and  to  arrange  our  treatment 
accordingly.  As  soon  as  the  necessity  of  such  a  meth- 
od of  procedure  is  once  recognized  we  will  at  once  un- 
derstand that  it  w^ould  be  bad  practice  to  refrain  from 
devoting  particular  attention  to  the  reduction  of  the 
obesity  that  so  frequently  complicates  these  lesions ;  in 
fact,  when  arranging  a  general  plan  of  treatment  we 
should  always  include  obesity  in  our  calculations.  The 
change  that  has  occurred  in  the  views  of  many  practi- 
tioners in  regard  to  this  matter  is  distinctly  manifested 
in  the  tendency  that  is  becoming  more  and  more  ap- 
parent not  to  send  these  patients,  as  heretofore,  to  some 
watering-place  like  Carlsbad,  Neuenhar  and  Vichy, 
where  the  patient  takes  a  course  of  alkaline  waters,  but 
to  send  them  every  year  to  some  w^atering-place  where 
corpulence  is  treated  by  a  carefully  selected  dietary  and 
where  the  heart  is  strengthened  by  such  measures  as 
baths,  massage,  gymnastic  exercises,  mountain-climb- 
ing, etc.       (Carlsbad    is    to    be    recommended  if  the 


52         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

amount  of  water-drinking  is  to  be  limited,  otherwise 
this  place  is  not  very  suitable;  Homburg,  Kissingen, 
Marienbad,  Nauheim,  Tarasp  have  cold-water  insti- 
tutes, so-called  "Terrapin"  watering-places.) 

/.  Other  Diseases  of  the  Organs  of  Locomotion.  In 
addition  to  chronic  rheumatism  and  gout  a  number  of 
other  diseases  that  interfere  with  locomotion  call  for 
reduction  cures  whenever  even  slight  degrees  of  obesity 
seem  to  render  the  movements  of  the  body  difficult.  To 
this  class  of  diseases  belong,  for  instance,  hemiplegia, 
chronic  diseases  of  the  spinal  cord,  many  cases  of  peri- 
pheral paralysis,  numerous  surgical  diseases  of  the 
joints  and  bones,  grave  cases  of  varicose  veins,  and 
chronic  ulcerations  of  the  legs,  etc.  It  is  clear,  of 
course,  that  a  reduction  of  excessive  fat  must  give 
much  relief  to  sufferers  from  all  these  lesions ;  neverthe- 
less this  point  is  not  sufficiently  appreciated  in  prac- 
tice. The  average  practitioner  is  usually  content  with 
half-way  measures  that  do  not  prevent  a  gradual 
increase  of  the  body  weight  and  in  this  way  lead  to  in- 
terference with  locomotion  of  these  patients  and  con- 
sequently with  metabolism;  in  this  way,  too,  the  con- 
dition of  such  patients  is  apt  to  become  aggravated, 
for  the  reason  chiefly  that  they  do  not  get  enough  ex- 
ercise. I  consider  it  an  important  and  an  urgent  part 
of  the  treatment  of  these  cases  to  decrease  the  body 
weight  wherever  this  is  possible.  The  best  method  con- 
sists in  beginning  a  regular  reduction  cure  combined 
with  exercise  and  strengthening  of  all  the  muscles  that 
are  still  capable  of  performing  their  function,  together 


OBESITY. 


53 


with  massage  and  physical  exercises;  the  latter  two 
methods  of  treatment  frequently  producing  brilliant  re- 
sults in  the  desired  direction.  The  effect  of  this 
treatment  is  so  apparent,  and  the  patients  are  so  grate- 
ful for  the  relief  bestowed  upon  them,  that  all  this 
should  encourage  us  to  attempt  this  method  of  therapy 
in  every  case  of  this  character  that  comes  under  our 
care. 

g.  Diseases  of  the  Nervous  System.  Some  of  the 
diseases  of  the  nervous  system  we  have  already  dis- 
cussed above,  those,  namely,  that  interfere  with  loco- 
motion; other  forms  of  nervous  disease  call  for  a 
short  discussion.  We  are  here  dealing  with  certain 
empiric  facts  that  are  not  quite  understood.  In  the 
first  place  reduction  cures  are  known  to  act  beneficially 
in  certain  forms  of  sciatica  and  of  other  neuralgias 
that  we  occasionally  encounter  in  obese  subjects.  I 
have  succeeded  in  several  instances  in  relieving  certain 
forms  of  supraorbital  and  of  occipital  neuralgia  that 
were  very  obstinate  by  instituting  a  reduction  cure 
even  after  all  other  customary  methods  of  treatment 
had  failed.  Cases  of  brachial  neuralgia  of  the  left 
side  are  also  suitable  for  treatment  of  this  kind,  partic- 
ularly those  forms  that  are  combined  with  pain  and 
oppression  in  the  region  of  the  heart.  This  variety  of 
neuralgia  may  either  be  one  of  the  symptoms  of  an- 
gina pectoris  or  may  appear  independently  and  with- 
out any  determinable  involvement  of  the  coronary  ar- 
teries of  the  heart.  It  is  impossible  to  predict  in  this 
or  any  other  form  of  neuralgia  whether  or  not  a  reduc- 


54         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

tion  cure  will  act  beneficially.  According  to  my  per- 
sonal experience  in  this  field,  good  results  are  obtained 
with  suf^cient  trequency  to  warrant  an  attempt  with 
this  method  of  treatment,  especially  as  improvement  in 
suitable  cases  is  witnessed  within  a  short  time,  i.e., 
within  two  or  three  weeks  after  the  reduction  cure  is 
begun.  In  view  of  this  fact  it  is  always  an  easy  matter 
to  determine  relatively  early  in  the  treatment  whether 
or  not  a  reduction  cure  is  going  to  lead  to  the  desired 
goal. 

In  hysteria  great  difficulties  are  offered.  Generally 
speaking  we  encounter  many  more  cases  of  hysteria 
that  are  poorly  nourished  and  call  for  an  increase  of 
the  fat  deposit  than  cases  of  hysteria  that  are  obese  and 
call  for  reduction  of  excessive  fat.  Cases  of  the  latter 
kind  are  by  no  means  rare,  however.  They  are  usually 
of  persons  who  "cannot"  or  "will  not,"  whose  will- 
power is  small.  Subjects  of  this  kind  usually  eat  a 
great  deal  and  are  at  the  same  time  lazy  so  that  they  do 
not  get  enough  muscular  exercise  and  do  not  develop 
any  energy  and  readily  grow  moderately  fat.  In  many 
cases  of  this  character  a  reduction  cure  carried  out  ac- 
cording to  correct  principles  and  combined  with  in- 
creasing demands  on  the  energy  of  the  patients  fre- 
quently constitutes  the  starting  point  for  a  new  life  and 
a  revival  of  strength  and  self-confidence.  Cures  of 
this  kind  can  only  be  successfully  carried  out  in  closed 
institutions. 

h.  Diabetes  mellitus.  The  statement  has  frequently 
been  made  by  different  clinicians  that  cases  of  diabetes 


OBESITY. 


55 


usually  feel  better  and  are  better  protected  against  the 
dangers  of  diabetes  if  they  are  fat  above  the  average. 
It  has  also  been  stated  that  diabetics  do  not  tolerate  re- 
duction cures  very  well.  I  have  myself  expressed  simi- 
lar views  in  another  place.  It  is  clear  therefore  that 
cases  of  diabetes  that  are  suffering  from  slight  de- 
grees of  obesity  should  never  undergo  a  reduction  cure, 
and  that  cases  suffering  from  medium  degrees  of  obesi- 
ty should  undergo  reduction  cures  only  under  excep- 
tional circumstances.  This  does  not,  however,  ex- 
clude the  necessity  of  reducing  fat  in  cases  of  diabetes 
that  are  very  obese  and  in  whom  the  excessive  fat  con- 
tent of  the  body  directly  endangers  the  life  of  the  pa- 
tient. In  certain  cases  diabetes  may  be  complicated 
by  attacks  of  heart  failure  (in  patients  afflicted  with 
valvular  lesions,  arteriosclerosis,  contracted  kidney  and 
simple  cardiac  weakness).  Patients  of  this  character 
should  be  relieved  of  any  excess  of  fat  even  if  the  obesi- 
ty is  only  of  medium  degree ;  only  in  this  way  can  the 
heart  be  protected  from  excessive  strain.  I  could 
quote  numerous  examples  to  illustrate  the  point  I  am 
making,  namely,  that  reduction  cures  are  not  neces- 
sarily always  counter-indicated  in  every  case  of  dia- 
betes. The  experience  of  the  physicians  of  Carlsbad 
and  of  Marienbad  also  supports  this  position.  In  re- 
gard to  the  best  method  to  be  adopted,  we  must  always 
remember  that  diabetes  tolerates  neither  long  continued 
reduction  of  flesh  nor,  on  the  other  hand,  sudden  loss 
of  weight  and  reduction  of  fat.  The  best  way  to  pro- 
duce the  desired  result  in  these  cases  is  to  institute  in- 


56         DISORDERS    OF    METABOLISM    AND    NUTRITION. 

termittent  reduction  cures;  in  other  words,  two  or 
three  pounds  at  the  utmost  should  be  made  to  dis- 
appear in  the  course  of  three  or  four  weeks;  this  re- 
duction treatment  should  be  repeated  every  three 
months.  The  reduction  of  fat  should  never  be  car- 
ried further  than  is  absolutely  necessary  for  the  con- 
servation and  the  protection  of  important  vital  func- 
tions. 

i.  Pulmonary  Tuberculosis.  Modern  phthisiothera- 
py,  according  to  Brehmer  and  Dettweiler,  calls  for 
abundant  nutrition  in  phthisis.  The  results  of  this 
treatment  are  so  extraordinary  and  so  satisfactory  that 
we  need  not  be  surprised  to  find  many  cases  of  tuber- 
culosis who  become  quite  obese.  As  a  rule  patients  are 
between  twenty  and  thirty-five.  The  majority  of  them 
were  so  fortunate  as  to  discover  the  disease  at  an  early 
stage,  and,  following  modern  methods  of  treatment, 
underwent  prolonged  rest  and  fattening  cures.  While 
I  recognize  that  a  systematic  fattening  treatment  is 
most  beneficial  in  tuberculosis  and  exercises  a  most  fa- 
vorable influence  on  the  course  of  the  disease,  and 
while  I  am  inclined  to  encourage  such  treatment  in  suit- 
able cases,  I  must  nevertheless  raise  my  voice  in  warn- 
ing against  any  exaggeration  of  this  mode  of  treat- 
ment. Unfortunately  we  find  such  exaggerations  are 
frequent  now-a-days.  The  natural  result  is  that  many 
cases  of  tuberculosis  are  converted  into  obese  indivi- 
duals whose  functional  powers  are  much  reduced.  I 
have  followed  a  number  of  sucl  cases  and  I  am  not  of 
the  opinion  that  the  condition  of  obesity  renders  these 


OBESITY. 


57 


people  more  fit  to  struggle  against  the  tulxircular  in- 
vasion and  the  inroads  of  the  disease  that  has  affected 
their  lungs.  As  long  as  they  can  lead  the  lazy  life  that 
is  imposed  on  them  in  the  different  institutions  where 
this  treatment  is  given,  everything  goes  well  and  they 
are  exhibited  as  shining  examples  and  the  pride  of  the 
institution.  As  soon,  however,  as  they  return  to  the 
routine  of  everyday  life  outside  of  the  institution,  the 
course  of  the  disease  usually  takes  a  rapid  turn  for  the 
worse,  and  a  second  course  of  fattening  treatment  is 
rarely  capable  of  saving  them.  In  other  cases  the  pa- 
tients retain  their  good  health  even  after  they  leave 
the  sanitarium,  but  these  subjects  have  gained  some  40 
or  50  pounds  and  are  consequently  decidedly  obese; 
they  suffer  from  this  condition  and  are  for  all  future 
time  exposed  to  the  dangers  that  this  state  engenders. 

I  should  like  to  insert  in  this  place  the  history  of  a 
case  of  this  character.  The  patient  was  a  woman  of  22 
years,  moderately  well  nourished  (weight,  58.8  kilos). 
After  her  first  puerperium  she  went  through  a  mild  at- 
,tack  of  pleuritis;  when  this  was  over  a  few  suspicious 
fine  rales  were  heard  at  the  right  apex,  and  after  pro- 
.longed  search  a  few  tubercle  bacilli  were  discovered  in 
the  sputum.  Domestic  circumstances  made  it  desir- 
able to  remove  this  patient  from  home.  At  this  time 
I  suggested  that  the  woman,  who  was  a  spoiled  and 
pampered  individual,  should  spend  the  winter  in  the 
mountains,  especially  as  she  was  a  very  vigorous  person 
otherwise.  It  was  decided,  however,  to  send  her  to  a 
sanitarium  that  was  situated  in  the  vicinity.  The  re- 
ports received  from  thi;  institution  were  very  favorable ; 
the  general  health  was  good,  there  was  never  any 


58  DISORDERS    OF    METABOLISM    AND    NUTRITION. 

fever,  and  the  weight  increased.  The  rales  at  the 
apex  disappeared  within  a  few  months  and  were  never 
heard  again  although  the  lungs  were  examined  twice  a 
week.  She  remained  in  this  institution  all  winter  long 
and  returned  home  at  the  expiration  of  seven  months 
apparently  perfectly  well  and  having  gained  19  kilos. 
At  home  she  voluntarily  continued  to  live  on  an  abun- 
dant fattening  diet  and  gained  10  kilos  more  during  the 
summer  months.  In  August  of  the  same  year  I  was 
consulted  a  second  time  as  the  patient  had  in  the  mean- 
time developed  difficulty  in  breathing  and  had  suffered 
several  fainting  attacks.  Nothing  abnormal  was  dis- 
covered in  the  lungs.  The  patient,  however,  presented 
all  the  features  of  advanced  obesity  of  the  anemic  type, 
with  alarming  weakness  of  the  heart  and  the  muscles. 
Several  months  of  careful  treatment  were  required  to 
reduce  the  weight  somewhat  and  to  increase  the  func- 
tional powers  of  the  heart  and  of  the  muscles.  This 
patient  has  never  again — two  years  and  a  half  have 
elapsed  since  that  time — regained  the  same  degree  of 
freshness  and  vigor  that  she  enjoyed  before  she  began 
the  sanitarium  treatment. 

It  might  be  argued  that  the  dangers  of  obesity  as 
compared  to  the  dangers  of  tuberculosis  are  very  msig- 
nificant.  This  is  undoubtedly  true,  but  might  we  not 
ask  whether  it  is  necessary  to  drive  off  one  foe  by 
opening  the  gates  to  another  one  ?  It  is  unnecessary  to 
attain  more  than  a  certain  optimum  of  nutrition  even  in 
the  treatment  of  tuberculosis;  in  fact,  it  is  bad  practice 
to  force  feeding  beyond  this  point.  I  am  glad  to  find 
that  Blumenfeld  occupies  the  same  stand  m  a  disserta- 
tion that  this  author  has  recently  taken.  I  would  cer- 
tainly hesitate  to  institute  a  reduction  cure  in  any  sub- 


OBESITY.  ^ 

ject  who  has  lately  passed  through  some  tubercular 
affection  of  the  lungs  or  who  is  actually  afflicted  in  this 
way ;  I  would  only  advise  this  in  case  the  condition  of 
obesity  itself  threatened  imminent  danger.  At  the 
same  time  I  feel  called  upon  to  warn  against  too  forced 
feeding  in  the  treatment  of  pulmonary  disease ;  in  other 
words,  I  advise  raising  nutrition  to  a  point  that  may 
be  considered  good  and  satisfactory  but  not  to  carry 
feeding  so  far  that  the  patient  becomes  actually  obese ; 
for  wherever  the  fat  deposit  becomes  excessive  there  is 
little  room  for  the  healthy  development  of  the  muscles. 
This  applies  still  more  to  sick  persons  than  to  well  sub- 
jects. And  as  the  strengthening  of  muscle  tissue 
guarantees  a  far  better  outlook  for  the  future  than  the 
accumulation  of  fat  I  can  only  warn  against  the  arti- 
ficial induction  of  obesity  in  these  cases. 

I  herewith  conclude  this  review  of  the  indications 
for  reduction  cures.  I  arn  fully  aware  of  the  fact  that 
I  have  been  unable  to  give  more  than  a  general  sketch. 
While  I  have,  I  believe,  done  full  justice  to  the  more 
important  points  that  must  be  considered,  I  realize,  at 
the  same  time,  that  in  practice  many  cases  will  be  en- 
countered in  which  a  decision  in  regard  to  the  advis- 
ability of  a  reduction  cure  will  have  to  be  arrived  at 
from  other  points  of  view  than  those  enunciated  in  this 
treatise;  the  principles  that  will  have  to  govern  this 
decision  in  each  individual  case  are  such  that  they  can- 
not be  discussed  from  a  general  therapeutic  stand- 
point. 


Hjecent  Publications 

International  Medical  Annual,  1904.      22  nd 

Year  of  Publication^  A  Year  Book  of  Treatment.  A  complete 
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Childbed   Nursing    with  Notes  on  infant  Feeding.     By 

Charles  Jewett,  A.M.,  M.D.,  Sc.  D.,  Professor  of  Obstetrics  and  Diseases 
of  Women  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y.  Fiftli 
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Syphilis — a  symposium.  Contributions  by  Seventeen  Distinguished 
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Physical  Diagnosis  in  Obstetrics,  a  Guide  in  Ante- 
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School  and  Hospital ;  Visiting  Physician  to  the  Mothers*  and  Babies' 
Hospital,  New  York.     8vo.     304  pages.     Illustrated.      Cloth,  $2.00  net. 

Consumption,  Pneumonia  and  Allied 

Diseases  of  the  Lungs,  Their  Etiology,  Pathology  and 
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clinic; Visiting  Physician  to  Rush  Hospital  for  Consumption.  8vo.  540 
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Formerly  Clinical  Professor  of  Venereal  Diseases,  Medical  Department,  Uni- 
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Blackwell's  Island;  one  of  the  Authors  of  **  A  System  of  Legal  Medicine," 
etc.,  etc.    8vo.    436  pages.    Illustrated.  Cloth,  $3.00  net. 

Favorite  Prescriptions  of  Distinguished 
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Nervous  Exhaustion,  (Neurasthenia),    its 

Hygiene,  Causes,  Symptoms  and  Treatment.  By  George  M. 
Beard,  M.D.,  Formerly  Lecturer  on  Nervous  Diseases  in  the  University  of 
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The  Sexual  Instinct.  Us  Use  and  Dangers  as  Affect- 
ing Heredity  and  Morals.  By  James  Foster  Scott,  B.A.  (Yale),  M.D., 
CM.  (Edinburgh);  late  Obstetrician  to  Columbia  Hospital  for  Women,  and 
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Treatment  of  Disease  by  Physical  Methods. 

riassage.  Electricity  and  Baths.  By  Thomas  S.  Dowse,  M.D.  (Ab- 
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E.  B.  TREAT  &  CO«,  24J-243  West  23d  Street,  New  York 


PLAIN   HINTS 

FOR 

BUSY  MOTHERS 

By  Marianna  Wheeler 

Superintendent  of  the  Babies'  Hospital,  New  York,  since  1891 

This  little  handbook  is  written  in  such  a  plain  and  simple 
manner,  that  no  one  could  fail  to  understand  its  directions. 
There  is  a  chapter  of  "Don'ts,"  several  pages  of  recipes  for 
gruels,  broths,  etc.,  suggestions  for  "emergencies,"  and  much 
valuable  information  gained  during  a  long  and  varied  practical 
experience  with  children  of  all  ages. 

Christian  Work,  New  York,  says:—"  Plain,  practical  and  wise. 
The  least  intelligent  mother  will  understand  it,  the  most  cultured  may 
profit  by  it.  An  admirable  feature  is  that  all  the  appliances,  clothing", 
etc.,  called  for,  are  of  the  simplest  and  cheapest.  It  will  be  easy 
enough  for  persons  of  means  to  increase  the  expense,  but  let  them 
retain  the  simplicity." 

Tlie  Wastiington  Post  says:— "The  author  has  found  by  ex- 
perience, that  in  the  care  of  babies,  cleanliness  is  next  to  godliness, 
and  in  a  very  clear  style  has  given  her  suggestions." 

The  Evening  News,  Detroit,  says:— "There  is  nothing  preten- 
tious about  the  book,  but  it  contains  many  valuable  hints  that  a  young 
mother  needs  to  know  to  preserve  the  little  life  given  into  her  charge." 

The  Northern  Christian  Advocate,  Syracuse,  says:— *' This 
volume  abounds  in  common  sense.  Directions  which,  if  followed, 
must  result  not  only  in  the  welfare  of  the  baby  but  of  the  household 
as  well." 

Buffalo  Medical  Journal  says:— "  This  book  is  written  in  a  suc- 
cinct style,  and  covers  the  essential  points  aimed  at.  If  it  could  reach 
the  mothers  for  whom  it  is  intended,  it  would  do  much  good." 

The  Christian  Observer,  Louisville,  Ky.,  says:—"  Many  a  baby 
would  have  better  health,  and  certainly  more  comfort  if  the  mother 
had  such  a  guide  as  this  little  book  to  help  her  in  the  management  of 
her  baby." 

The  Virginia  Medical  Semi-Monthly,  Richmond,  says:— " The 

style  is  plain  and  simple,  and,  unlike  many  such  publications,  this 
book  is  full  of  common  sense  advice." 

12ino,  Illustrated,  Leatherette,  postpaid,  35cts,  aet 


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A      MANUAL     OF 

GtllLDBED  NURSING 

WITH  NOTES  ON 

INFANT  FEEDING 

By  Charles  Jewett,  A.M.,  M.D.,  Sc.D. 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Long 
Island  College  Hospital,  Brooklyn,  N.  Y. 


This  book  will  be  found  of  service  not  only  to  doctors  and 
professional  nurses  but  to  mothers  and  all  interested  in  ob- 
stetrics. It  is  a  most  suggestive  work,  full  of  hints  regarding 
the  latest  practice  and  methods.  The  added  chapter  on 
"  Infant  Feeding  "  is  of  great  value. 

Medical  Record,  New  York,  says:— "This  little  book  is  especially 
commendable  from  its  great  clearness  and  preciseness  of  expression.  1 1 
would  seem  to  be  impossible  even  for  a  layman  of  less  than  average 
iiiteliigence  to  misunderstand  any  of  its  directions.  The  concise,  dog- 
matic statements  are  calculated  to  impress  upon  the  reader  the  essen- 
tial facts  which  need  to  be  kept  in  mind  at  the  bedside.  The  chapter 
on  the  care  of  the  child  is  quite  comprehensive.  Artificial  feeding,  a 
subject  which  has  assumed  such  prominence  in  recent  years,  is  care- 
fully described." 

Medical  Standard,  Chicago,  says:—"  This  little  book  is  a  marvel 
of  condensed  information," 

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sion and  none  of  the  laity  can  read  this  book  without  learning  much 
from  the  accurate  descriptions  and  terse  directions  therein  contained. 
It  is  a  model  of  compact  information." 

Yale  Medical  Journal  says: — "  The  book  is  an  excellent  summary 
of  the  practical  points  in  childbed  nursing  and  infant  feeding." 

Medical  Bulletin,  Philadelphia,  says:— "That  the  rules  laid  down 
in  this  book  are  good  is  a  consequence  of  the  author's  experience  and 
ability.  That  they  are  brief  is  commendable  in  view  of  their  intended 
purpose.  The  book  can  be  commended  to  the  classes  for  whom  it  is 
intended," 

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A  System  of 

LEGAL  MEDICINE 

By  ALLAN  McLANE  HAMILTON,  M.  D. 

Professor  of  Mental  Diseases  Cornell  University,  Consulting 
Physician  to  the  Insane  Asylums  New  York  City,  Etc., 

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